Running head: ACES AND MATERNAL EDUCATION Adverse Childhood Experiences and Maternal Education Melissa Gohlke Arizona State University 1 ACES AND MATERNAL EDUCATION 2 Abstract Adverse childhood experiences (ACEs) are traumatic events experienced during childhood that have negative effects starting as a child and extending into adulthood. The presence of multiple ACEs increases negative mental, physical, and behavioral health outcomes. Children of parents who have experienced ACEs are at a higher risk of experiencing ACEs themselves, creating an intergenerational cycle of trauma between parents and their children. Evidence suggests that parenting education can reduce the impact of ACEs and potentially eliminate poor health outcomes. The literature revealed that parenting education was found to increase parenting competency, which will in turn reduce the impact of ACEs on children. The purpose of this evidence-based project is to evaluate parenting competency and parenting self-efficacy after implementing six parenting workshops. The workshop topics consist of: (a) stress management, (b) understanding trauma, (c) positive parenting, (d) positive discipline, (e) play, and (f) learning development and support. The workshops were delivered at a community residential facility for women seeking recovery from abuse, incarceration, chemical dependency and other lifecontrolling problems. Participants included 10 female residents. Demographics, ACE scores, pre and post Parenting Sense of Competency Scale, and a post intervention satisfaction questionnaire and discussion were used to collect data from the participants. Mothers’ ACE scores ranged from 2-9. The parenting self-efficacy score increased in the subgroup that attended all six workshops. All of the mothers agreed that the workshops would help with parenting their children. The findings suggest that parenting education increases parenting knowledge and self-efficacy, and may reduce the impact of ACEs on children. Keywords: parents, children, adverse childhood experiences, parent child relation, parenting education ACES AND MATERNAL EDUCATION 3 Adverse Childhood Experiences and Maternal Education Adversity comes in many forms throughout the lifespan. Large traumatic events may be easily recognized as negatively impacting one’s life, but the chronic events or situations may not be apparent on the surface. Adverse childhood experiences (ACEs) are linked to short and longterm physical and mental health problems (The Child & Adolescent Health Measurement Initiative [CAHMI], 2017; Wade, Shea, Rubin, & Wood, 2014) and ways to decrease these effects are continually being explored. This project aims to explore the intergenerational cycle of ACEs, and an intervention to help break that cycle. Background and Significance Problem Statement ACEs are traumatic events experienced during childhood such as family dysfunction (divorce, single parent, incarcerated parent, homelessness), abuse, neglect, violence in or outside of the home, and living with someone who has mental health problems or addiction (CAHMI, 2017; Felitti et al., 1998; Woods-Jaeger, Cho, Sexton, Slagel, & Goggin, 2018). These experiences impact both children and adults, and are associated with health problems throughout the lifespan. ACEs are more common than previously recognized. In the United States (U.S.), 46.3% of children from 0-17 years old have experienced one or more ACEs, and 21.7% have experienced two or more ACEs. Arizona ranks number one in the country in percentage of children with two or more ACEs at 30.6% (CAHMI, 2017). Evidence suggests that the presence of multiple ACEs, rather than one or none, significantly increases negative mental, physical, and behavioral health outcomes (CAHMI, 2017; Felitti et al., 1998). Further, an intergenerational cycle has been found. The presence of ACEs in parents is positively associated with the number of ACES AND MATERNAL EDUCATION 4 ACEs experienced by their children (Lê-Scherban, Wang, Boyle-Steed, & Pachter, 2018; Schofield et al., 2018; Schofield, Lee, & Merrick, 2013; Woods-Jaeger et al., 2018). Purpose and Rationale ACEs are affecting both children and adults throughout the U.S. Evidence reveals that ACEs have short and long term impacts on health, however research is beginning to shift toward early interventions to reduce those effects. The purpose of this project is to explore and summarize current literature regarding ACE interventions, specifically focusing on maternal education, and applying an intervention to help break the intergenerational cycle of childhood adversity. Internal Evidence A community residential program for women seeking recovery from abuse, incarceration, chemical dependency, and other life-controlling problems has identified the problem of an intergenerational cycle of trauma between the female residents and their children who also reside at the center. The childcare supervisor, program director, and child counselor report observing the mothers feeling unsure of how to play with their children and witness yelling and lack of effective parenting skills. They also notice children who have behavioral and physical aggression problems starting at young ages. The center strives to support mothers in their journey to recovery and transformation, and have a positive impact regarding the growth and development of their children. PICOT Question The intergenerational cycle of trauma and childhood adversity is a significant problem at the local community center, in Arizona, and in the United States. Without breaking the cycle, the effects of ACEs will continue through generations. This discussion has led to the clinically relevant PICOT question: In mothers who have experienced adverse childhood experiences, how ACES AND MATERNAL EDUCATION 5 do parenting workshops compared to no current education affect their knowledge of positive parenting strategies, and parenting self-efficacy to help break the intergenerational cycle of ACEs? Literature Review Felitti et al. (1998) conducted the first study to examine the correlation between adverse childhood exposures and leading causes of death in the U.S. A dose response relationship between exposure to ACEs and leading causes of death were found (Felitti et al., 1998). The health problems correlated with ACE exposure included alcoholism, drug abuse, smoking, depression, suicide attempt, sexually transmitted infections, obesity, heart disease, lung disease, liver disease, and cancer (Felitti et al., 1998). In addition to having a higher risk for health problems in adulthood, recent studies reveal that ACEs are correlated with developmental and cognitive delays, and behavior issues in childhood (CAHMI, 2017). Steel et al. (2016) found that maternal exposure to ACEs was significantly associated with parental stress, and ACEs are a risk factor for the continuation of poor parent-child attachment throughout generations. Another study discovered that the number of ACEs experienced by parents was positively associated with the number of ACEs experienced by their children (Schofield et al., 2018). Woods-Jaeger et al. (2018) identified an intergenerational cycle of ACEs, and parenting stressors related to ACEs after interviewing low-income parents. LêScherban et al. (2018) found that as the number of parent ACEs increased, so did the likelihood of poor overall health of their child. The American Academy of Pediatrics (AAP) reviewed current literature to create recommendations for modifiable resilience factors to reduce the impact of ACEs (Traub & Boynton-Jarrett, 2017). The AAP found that constructive parent-child relationships have a ACES AND MATERNAL EDUCATION 6 positive effect on ACE resilience (Traub & Boynton-Jarrett, 2017). The AAP recommends parenting education focused on responsive parenting, understanding parental role in trauma healing, and taking a group-based approach (Traub & Boynton-Jarrett, 2017). Purewal Boparai et al. (2018) found that successful interventions included strong parenting skills, early intervention, and a high level of intervention engagement. Positive parenting practices such as support, warmth, and strong attachment were associated with better overall intervention outcomes (Purewal Boparai et al., 2018). Lindstrom Johnson, Elam, Rogers, & Hilley (2018) discovered that trauma-informed parenting interventions had a positive effect on child psychosocial outcomes. Muzik et al. (2015) conducted a pilot study of a parenting program consisting of 10 group sessions for high-risk mothers, which focused on coping strategies and behavior management of their children. After the program intervention, there was a positive association with reduced depressive and posttraumatic stress disorder (PTSD) symptoms, and care-giving helplessness (Muzik et al., 2015). The Academic Pediatric Association (APA) created a national agenda to address ACEs and promote awareness and education (Bethell et al., 2017). Parent education regarding the science of ACEs, ways to prevent ACEs, trauma healing, and cultivating resilience were all recommended by the APA (Bethell et al., 2017). Bellis et al. (2017) revealed that having reliable adult support significantly decreased the impact of ACEs on diet, smoking, alcohol consumption, and mental well-being. Ziv, Sofri, Capps Umphlet, Olarte, and Venza (2018), found that negative parental behaviors were positively associated with their children exhibiting negative behaviors and perceptions. There are associations between a poor parent-child relationship, high ACE scores, and the negative impact of ACEs. Parental education is a recommended intervention to reduce the ACES AND MATERNAL EDUCATION 7 impact of ACEs on children. Parental education regarding positive parenting practices may lesson the impact of ACEs on their children. Efforts toward breaking the intergenerational cycle of trauma rely heavily on parent involvement and education. Search Strategy A search of three databases was conducted to review parenting interventions in relation to ACEs. PsychINFO, PubMed, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) were chosen for their relevance to medicine, mental health, and evidence-based practice. The key terms used were: mother, children, adverse childhood experiences, parent child relations, and parenting education. There was small variation of terms between databases. PsychINFO Database Search PsychINFO yielded the most relevant results. The search began with (parent child relation) AND (adverse childhood experiences) OR (childhood adversity) OR (childhood trauma), which resulted with 1,799 articles. This was too broad, leading further searches to use only adverse childhood experiences. After trying different combinations of parents, children, adverse childhood experiences, and education, the most beneficial term string was (parenting education) AND (parent child relations) AND (single mother). PubMed Database Search PubMed yielded the second best results. The first two searches were broad in relation to the topic of interest: ((childhood trauma) AND education) AND behavior – 475 results, and ((parents) AND children) AND adverse childhood experiences – 309 results. Adding education to the last search string yielded a manageable, relevant set of 68 articles. In the remainder of the search, more specific terms were added and experimented with: (a) homeless, (b) resilience, and (c) intergenerational. This narrowed the search, but did not provide new results. ACES AND MATERNAL EDUCATION 8 CINAHL Database Search The initial search string “parents AND children AND adverse childhood experiences” yielded only 147 results. Adding education further narrowed results to 26. More specific terms were experimented with in hopes of finding new material, but using intergenerational, high-risk mother, and homeless with initial terms had little reward. The combination of “parenting education AND parent child relations AND stress” returned 61 results, with two new articles for use. Final Yields After searching the databases, reviewing abstracts, and scanning reference sections, 30 articles were retained. Inclusion criteria were impact of ACEs on children and mothers, interventions focused on parents, outcomes related to maternal knowledge, stress, and behavior, and outcomes related to child health and development. The exclusion criterion was child only based interventions. Critical Appraisal and Synthesis of Evidence Ten studies were retained for this evaluation. All were published within the past five years. The level of evidence ranged from level I to level IV, including one systematic review (SR), two meta-analyses (MA), three randomized controlled trials, one non-randomized controlled trial, two non-randomized non-controlled trials, and one sub-study of a randomized controlled trial. The study samples were homogenous. Of the studies that included gender percentages and mean ages, females were the majority of the participants with mean ages between 24-34 years. All studies took place in a community setting, except for the SR and MAs, which did not specify setting for all studies in the reviews. Overall strengths of the studies were publication in the past five years, low attrition rates, no bias, and reliable measurement tools. ACES AND MATERNAL EDUCATION 9 Weaknesses of several of the studies were lack of control group, small sample sizes, and the majority of results were parent reported (Appendix A). The measurement tools used were heterogeneous, and all were reliable and valid. There were common themes of measurement among the tools: parent mood, behavior, or knowledge, child behavior, and child health. The majority of the studies were rooted in attachment or social learning theories. The interventions were homogenous. All addressed positive parenting practices through some form of education or program. The intervention delivery varied, but most were parent-only, group setting, and instructor-led. Three studies included education delivered by video and four included some type of one-on-one interview or education (Appendix B). Data analysis used was heterogeneous. The most frequently occurring methods were ANOVA and Cohen’s d (Appendix A). The outcomes were homogenous with every study achieving significant improvement in parent positive parenting competence, except for a single study that did not directly measure parent’s knowledge. Additional outcomes post positive parenting education varied. Two studies revealed improved parent mental health while one found no significant change. Four studies measured parent stress level, half revealed a significant decrease in stress, and the other half did not. Of the three studies that measured parent self-efficacy, all revealed significant improvement. Harsh discipline was reduced in four studies, and one study found no significant difference. Four studies measured child behavior, and all found a significant improvement. Child health was measured in two studies, and both revealed improvement (Appendix B). Conclusions from Evidence and the Project The evidence suggests that positive parenting education interventions conducted in a community setting both in groups or one-on-one can improve positive parenting competence. ACES AND MATERNAL EDUCATION 10 Instructor-led and video education are both effective. Positive parenting education and programs can lead to increased parent self-efficacy and improved child behavior. Positive parenting education may also lead to reduced parent stress, reduced harsh discipline, and improved parent mental health. This evidence led to the development and delivery of group based, in person educational workshops for mothers focusing on self-efficacy, trauma, and parenting skills. Theory Application The most frequently used theories in the reviewed studies were attachment theory and social learning theories (Appendix B). The social cognitive theory (SCT) is based on the original social learning theory, but the major concept in SCT is self-efficacy. Considering self-efficacy provides insight to the learner’s belief that they can carry out a behavior or achieve a goal. SCT accounts for three factors that determine human behavior: cognitive (personal experience), environment, and behavior (Polit & Beck 2017). These factors are particularly useful in the community setting because there are many environmental factors influencing learning. Cognitive factors such as knowledge and attitudes, and behavioral factors such as skills and practice are also important to identify when learning something new. Evidence Based Practice Model The Stetler Model uses a five-phase approach to the implementation of evidence-based practice: (a) preparation, (b) validation, (c) comparative evaluation/decision making, (d) translation/application, and (e) evaluation (Stetler, 2001). The step-wise approach makes the model easy to follow and provides insight regarding the appropriate actions in each step (Appendix C). Phase I: Preparation is particularly useful to the community center needs. It includes taking current evidence from literature, but also considers external factors such as needs of the organization, and internal factors like personal beliefs and appeal of interventions. Phase ACES AND MATERNAL EDUCATION 11 II: Validation involves critiquing and evaluating evidence (Appendix A). Phase III: Comparative evaluation/decision making is synthesizing the evidence and making decision for use (Appendix B). Phase IV: Translation/application involves designing and implementing the intervention and the final phase is evaluation of the intervention (Stetler, 2001). Phase IV was heavily focused on developing the workshops based on evidence found for effective parenting education and tailoring the intervention to the organization’s needs. Phase V involved measurement of the outcomes after implementation of the workshops at the organization. This intervention has similar core concepts as other parenting/maternal education programs, but also involves a degree of innovation. The parenting workshops were heavily interactive, and promote discussion throughout the learning. They took place in an informal, workshop setting, and included additional subjects like trauma education, play, and how to support learning development. These subjects are not included in many other parenting programs that mainly focus on parent-child relationships, positive parenting, and discipline. Methods Population and Setting The participant population was women who were 18 years or older, a mother with children of any age, English speaking, and a resident at the community residential recovery program center. The center is located in an urban neighborhood, and is gate protected. The mothers and their children reside at the center in single-family apartments for the 12 months it takes to complete the recovery program offered by the center. Participant recruitment was done by the child counselor at the center based on the above criteria, and appropriate place within the program. The intervention took place in a classroom, roundtable setting. Ethical considerations included the intervention being voluntary, ability to withdraw at any point during the ACES AND MATERNAL EDUCATION 12 intervention, and having a counselor available at all times during the intervention in case of participant distress. Not collecting a written consent, and never collecting or recording participant identifiers ensured human subjects protection and confidentiality. The project was reviewed and approved by the Arizona State University Institutional Review Board prior to implementation. Intervention The intervention consists of six parenting workshops: (a) stress management, (b) understanding trauma, (c) positive parenting, (d) positive discipline, (e) play, and (f) learning development and support. The workshops were created by the student and tailored specifically to the mothers at the community residential center. The topics were chosen based on common themes found in the literature and amongst evidence based parenting programs. The workshops and workbook were developed over several months during summer of 2019, and based on parenting resources from organizations such as the Centers for Disease Control and Prevention (CDC), the National Child Traumatic Stress Network, and the National Association for the Education of Young Children. The hour-long workshops were delivered over six weeks in October and November of 2019, and included a slide presentation, in workshop activities, discussion, and homework. The workbook provided to the participants enabled them to follow along with the material, write down notes, perform weekly homework assignments, and use as a resource to reference after completion of the workshops. There were additional resources in the workbook such as CDC positive parenting handouts, a gratitude journal, and a child behavior log. ACES AND MATERNAL EDUCATION 13 Data Collection Data collection took place prior to the first workshop, and after the sixth workshop. A demographic questionnaire, an ACE questionnaire, and the Parenting Sense of Competence Scale (PSOC) were administered prior to the first workshop. The demographic questionnaire addressed: (a) age, (b) level of education, (c) number of children, (d) age of children, and (e) whether the participant had attended a parenting class in the past. The ACE questionnaire has a series of 10 questions, which each identify an adverse childhood experience, and the total of questions answered “yes” equals the number of ACEs experienced by the participant. The PSOC is a 17-item Likert scale that measures parenting competency with two subscales, parenting selfefficacy (items 1, 6, 7, 10, 11, 13, & 15) and parenting satisfaction (items 2, 3, 4, 5, 8, 9, 12, 14, & 16). Attendance of workshops was tracked throughout the intervention. After the sixth workshop, the PSOC was administered again to measure changes in parenting competency and parenting self-efficacy after the workshops. An intervention satisfaction survey was also administered with questions about intervention content, delivery, and applicability to their parenting. A post workshops discussion took place with specific questions regarding positive areas of the workshops, how the workshops affected the relationships with their children, and areas for improvement. After the pre and post workshops questionnaires were completed, demographic information, ACE scores, PSOC scores, and intervention satisfaction results were compared. Descriptive statistics were used to compare data and determine any statistical significance and common trends. Budget and Funding The budget plan (Appendix D) was cost effective because the workshops did not need to be purchased, and the meeting space was provided by the center. The bulk of costs came from ACES AND MATERNAL EDUCATION 14 printing materials, workbook binders, and statistics software for data entry and analysis. The student provided funding. There was no use of grant or sponsorship money. Results Of the 10 participants in the workshops, all 10 were included in data collection and analysis (N=10). All 10 of the mothers attended at least half of the workshops. The mothers’ ages ranged from 23-40 years old (M=29). The mothers’ ACE scores ranged from two to nine with 80% experiencing four or more ACEs. The mothers’ number of children ranged from 1-5 (M=3) with ages between 9 months old to 16 years old (M=6). Education levels varied from less than high school to some college, with a majority (60%) of the mothers having some or less than high school education. The majority (70%) of the participants had attended a parenting class in the past. Descriptive statistics were used to analyze the data. The PSOC was used as a preintervention and post-intervention assessment of change in overall parenting sense of competence, and parenting self-efficacy with the self-efficacy subscale of the PSOC. For the total population (N=10), two-tailed paired samples t-tests were conducted for each the PSOC Pre-Test and PSOC Post-Test, and the Pre-Test Self-Efficacy subscale and Post-Test SelfEfficacy subscale to examine whether the mean differences were significantly different from zero. The result of the two-tailed paired samples t-test examining the PSOC Pre-Test and PSOC Post-Test was not significant based on an alpha value of 0.05, t(9) = -1.72, p = .120, indicating the null hypothesis cannot be rejected. The result of the two-tailed paired samples t-test examining the Pre-Test Self-Efficacy subscale and Post-Test Self-Efficacy subscale for all participants was not significant based on an alpha value of 0.05, t(9) = -2.07, p = .069, indicating the null hypothesis cannot be rejected. This finding suggests the difference in the means of the ACES AND MATERNAL EDUCATION 15 PSOC and the Self-Efficacy subscale for the total population was not significantly different from zero. There were four participants who fully attended all six workshops. For the participants who attended all of the workshops (N=4), two-tailed paired samples t-tests were conducted for each the PSOC Pre-Test and PSOC Post-Test, and the Pre-Test Self-Efficacy subscale and PostTest Self-Efficacy subscale to examine whether the mean differences were significantly different from zero. The result of the two-tailed paired samples t-test examining PSOC Pre-Test and PSOC Post-Test the was not significant based on an alpha value of 0.05, t(3) = -0.76, p = .502, indicating the null hypothesis cannot be rejected. The result of the two-tailed paired samples ttest examining the Pre-Test Self-Efficacy subscale score and Post-Test Self-Efficacy score was significant based on an alpha value of 0.05, t(3) = -4.00, p = .028, indicating the null hypothesis can be rejected. The post workshops questionnaire revealed that 100% of participants agreed to strongly agreed that they were satisfied with the delivery and information provided within the workshops. Participants felt that the information they learned from the workshops will assist them in parenting their children. All of the participants attended at least 50% of the workshops, which was an inclusion criterion for data analysis. Participants’ responses during the post workshops discussion were all positive, which was consistent with the positive attitudes and eagerness to learn from them throughout the workshops. There were five questions to prompt the discussion. When asked what the participants liked about the workshops, response themes included the topics covered, dialogue throughout the workshops, and learning ways to help their children. One participant stated, “I liked that it covered a lot of topics that were concerning me with my children. It answered a lot ACES AND MATERNAL EDUCATION 16 of questions that I had been having.” When asked how the information from the workshops affected the participants’ relationships with their children, response themes included an overall improvement in relationships and more bonding. One participant explained, “The information from the workshops helped me to have a less stressful and more positive relationship and I’m able to appreciate my experiences with them more.” Another participant stated, “It definitely improved my relationship with my oldest son especially because I’ve used these lessons to teach myself on how to connect with my son.” When asked what the mothers would like to learn more about in regards to parenting, response themes included positive discipline, and more information on older children. The response of a mother with an 11-year-old son was, “How to have the sex talk.” When asked about workshop improvement suggestions, only one mother had a suggestion. She suggested, “Maybe more dialogue.” When participants were asked if they would like to share anything in addition to their previous responses, one mother said, “I highly recommend it for moms, especially new moms. I think it should be expanded for moms and dads.” Another stated, “I like how positive parenting makes it easier. I learned this from the workshops.” Impact on Systems The six-week parenting workshops have the potential to become a permanent part of the current 12-month program at the center. It could be offered to mothers, and potentially to child caregivers at the center. This would give mothers and caregivers parenting knowledge and selfefficacy, which will improve the care delivered to the children at the center. Positive parent/caregiver-child relationships and having a positive adult role model will help reduce the impact of ACEs on the children at the center (Bellis et al., 2017; Purewal Boparai et al., 2018). ACES AND MATERNAL EDUCATION 17 ACEs negatively impact lives from youth to adulthood. Early interventions can help to reduce the effects of ACEs. In the community residential program, the women have experienced adversity in childhood and in adulthood. Their children have experienced at minimum two ACEs (the events that led their mother to the center and family dysfunction), and are at risk for experiencing adversity in adulthood too. One strategy to help the children is educating their mothers to enhance parenting practices and promote healthy relationships. With the implementation of parenting workshops for the mothers at the residential center, parenting practices may be improved, and the effects of trauma for their children should be less. Educating mothers regarding the impact of trauma on their children, and providing them with skills to nourish their home environment and relationships will positively impact both the mother and child, and may impact future generations too. Workshops Sustainability The workshops were created and tailored to mothers residing at the community residential center, and are available to the center at no cost. The workshops materials, including instructor notes, slide presentations, and workbook contents, have been put together for use by the center. The center would need an individual who is willing to conduct the workshops, and learn the material. The workshops would need to be included in the timing of the current curriculum offered at the center as well. Time for the workshops was allotted for implementation of this project, so this is attainable. If there is an individual willing to take over the workshops, the workshops could be sustained at the center at no cost. ACES AND MATERNAL EDUCATION 18 Discussion Summary and Conclusions The ACE scores of the mothers were moderate (1-3) to high (4+) indicating that their childhood adversity put them at high risk for negative mental, physical, behavioral, and social health outcomes (CAHMI, 2017; Felitti et al., 1998). The mothers’ high ACE scores also puts their children at a higher risk for negative health outcomes (Lê-Scherban et al., 2018; Schofield et al., 2018). Although the scores of the pre and post PSOC were not significant, all of the mothers believed that the information they learned from the workshops would help them with parenting their children. The increase in parenting self-efficacy was statistically significant in mothers who attended all six workshops suggesting that the workshops can improve parenting selfefficacy. The post workshops discussion provided valuable information on the mother’s thoughts about the workshops. All of the mothers had a positive response to the workshops, many stating that the information they learned helped them become better mothers, and their parent-child relationships improved. All but one mother reported an improvement in their relationships with their children, which has been found to lead to an increase in ACE resilience in children (Traub & Boynton-Jarrett, 2017). Overall, the workshops were well received by the mothers. Limitations and Barriers There were several limitations and barriers encountered in this project. Limitations included a small sample size and use of a pilot parenting program. The center was unwilling to use a pre-designed parenting program. This led to the limitation of not knowing if the intervention would be helpful for mothers. It also presented the challenge of creating parenting workshops, which was time intensive for the student. Additional limitations included being ACES AND MATERNAL EDUCATION 19 unaware of the ages of the mothers’ children prior to the workshops, and an overall low education level of the mothers. The barriers encountered with the center included poor communication, organization, and lack of resources. The room the workshops were conducted in was missing resources such as a computer many days, and led to delays in and shortening of workshops. Children were not allowed in the workshops, so the center explained to the mothers that childcare would be provided during the workshops. Unfortunately, there were several workshops where childcare was not provided by the center and the mothers were searching for childcare as the workshops started, leading to delays and missed material in some instances. Findings and Recommendations The difference in PSOC pre and posttest scores was not statistically significant, however the majority of participants’ scores increased on the posttest, and all participants agreed that the information from the workshops would help them with parenting their child. This is consistent with other literature, which revealed positive parenting knowledge increased with parenting education (Appendix B). The finding of increased parenting self-efficacy in mothers who attended all six workshops is consistent with other studies that measured parenting self-efficacy after parenting education (Brennan et al., 2016; Durrant et al., 2014; Muzik et al., 2015). The project revealed an intergenerational correlation with ACEs where both the mothers and their children have experienced ACEs, which is consistent with literature that identifies an intergenerational cycle of trauma (Lê-Scherban et al., 2018; Schofield et al., 2018; Woods-Jaeger et al., 2018). Future studies would benefit from reassessing participants’ parenting knowledge several months beyond the intervention to identify any increase or decrease after time has passed. It would also be beneficial to assess the children’s behaviors and parent-child relationships in ACES AND MATERNAL EDUCATION 20 conjunction with the parenting workshops, so areas of need and improvement could be identified. If able to obtain a substantial sample size, an inclusion criterion of child’s age would be helpful in ensuring the intervention content is appropriate and meaningful to the mothers. In addition, having different sets of workshops for parents with children in different stages of life may be beneficial, such as early childhood, middle childhood, and teen years. Obtaining the children’s ACE scores to compare them to the mothers’ ACE scores would assist in evaluating the extent of intergenerational trauma. Finally, gathering mental, physical, and behavioral health information for the mothers and their children would be valuable to identify the negative impacts from ACEs. Conclusion ACEs are a widespread problem and are correlated with health problems across the lifespan. There are several interventions that can help prevent and reduce the negative impact of ACEs. This project revealed that mothers are eager to learn, enjoyed receiving parenting education, and believed the parenting information they learned would assist them in parenting their children. Continuing to explore ways to help prevent and reduce ACE impacts, and connecting individuals with ACE focused resources will positively affect population health. Running head: ACES AND MATERNAL EDUCATION 21 References Brennan, A. L., Hektner, J. M., Brotherson, S. E., & Hansen, T. M. (2016). A nonrandomized evaluation of a brief nurtured heart approach parent training program. Child & Youth Care Forum, 45(5), 709–727. https://doi.org/10.1007/s10566-016-9351-4 Bellis, M. A., Hardcastle, K., Ford, K., Hughes, K., Ashton, K., Quigg, Z., & Butler, N. (2017). Does continuous trusted adult support in childhood impart life-course resilience against adverse childhood experiences - a retrospective study on adult health-harming behaviours and mental well-being? BMC Psychiatry, 17(1), 110. https://doi.org/10.1186/s12888-0171260-z Bethell, C. D., Solloway, M. R., Guinosso, S., Hassink, S., Srivastav, A., Ford, D., & Simpson, L. A. (2017). Prioritizing possibilities for child and family health: An agenda to address adverse childhood experiences and foster the social and emotional roots of well-being in pediatrics. Academic Pediatrics, 17, 36-50. https://doi.org/10.1016/j.acap.2017.06.002 The Child & Adolescent Health Measurement Initiative. (2017). A national and across-state profile on adverse childhood experiences among U.S. children and possibilities to heal and thrive. Retrieved from http://www.cahmi.org/wp-content/uploads/2018/05/aces_brief_final.pdf Durrant, J. E., Plateau, D. P., Ateah, C., Stewart-Tufescu, A., Jones, A., Ly, G., … Tapanya, S. (2014). Preventing punitive violence: Preliminary data on the positive discipline in everyday parenting (PDEP) program. Canadian Journal of Community Mental Health, 33(2), 109–125. https://doi.org/10.7870/cjcmh-2014-018 Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., … Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many ACES AND MATERNAL EDUCATION 22 of the leading causes of death in adults: The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine, 14(4), 245-258. https://doi.org/10.1016/S0749-3797(98)00017-8 Juffer, F., Struis, E., Werner, C., & Bakermans-Kranenburg, M. J. (2017). Effective preventive interventions to support parents of young children: Illustrations from the video-feedback intervention to promote positive parenting and sensitive discipline (VIPP-SD). Journal of Prevention & Intervention in the Community, 45(3), 202-214. https://doi.org/10.1080/10852352.2016.1198128 Lachman, J. M., Cluver, L., Ward, C. L., Hutchings, J., Mlotshwa, S., Wessels, I., & Gardner, F. (2017). Randomized controlled trial of a parenting program to reduce the risk of child maltreatment in South Africa. Child Abuse & Neglect, 72, 338-351. https://doi.org/10.1016/j.chiabu.2017.08.014 Leijten, P., Raaijmakers, M. A. J., Orobio de Castro, B., Van den Ban, E., & Matthys, W. (2017). Effectiveness of the incredible years parenting program for families with socioeconomically disadvantaged and ethnic minority backgrounds. Journal of Clinical Child & Adolescent Psychology, 46(1), 59–73. https://doi.org/10.1080/15374416.2015.10388 Lê-Scherban, F., Wang, X., Boyle-Steed, K. H., & Pachter, L. M. (2018). Intergenerational associations of parent adverse childhood experiences and child health outcomes. Pediatrics, 141(6). https://doi.org/10.1542/peds.2017-4274 Lindstrom Johnson, S., Elam, K., Rogers, A. A., & Hilley, C. (2018). A meta-analysis of parenting practices and child psychosocial outcomes in trauma-informed parenting ACES AND MATERNAL EDUCATION 23 interventions after violence exposure. Prevention Science, 19(7), 927-938. https://doi.org/10.1007/s11121-018-0943-0 Ludmer, J. A., Salsbury, D., Suarez, J., & Andrade, B. F. (2017). Accounting for the impact of parent internalizing symptoms on parent training benefits: The role of positive parenting. Behaviour Research and Therapy, 97, 252-258. https://doi.org/10.1016/j.brat.2017.08.012 Muzik, M., Rosenblum, K. L., Alfafara, E. A., Schuster, M. M., Miller, N. M., Waddell, R. M., & Kohler, E. S. (2015). Mom power: preliminary outcomes of a group intervention to improve mental health and parenting among high-risk mothers. Archives of Women’s Mental Health, 18(3), 507–521. https://doi.org/10.1007/s00737-014-0490-z Pereira, M., Negrão, M., Soares, I., & Mesman, J. (2014). Decreasing harsh discipline in mothers at risk for maltreatment: A randomized control trial. Infant Mental Health Journal, 35(6), 604–613. https://doi.org/10.1002/imhj.21464 Polit, D. F., & Beck, C. T. (2017). Nursing research: Generating and assessing evidence for nursing practice (10th ed.). Philadelphia, PA: Wolters Kluwer. Purewal Boparai, S. K., Au, V., Koita, K., Oh, D. L., Briner, S., Burke Harris, N., & Bucci, M. (2018). Ameliorating the biological impacts of childhood adversity: A review of intervention programs. Child Abuse & Neglect, 81, 82-105. https://doi.org/10.1016/j.chiabu.2018.04.014 Schofield, T. J., Donnellan, M. B., Merrick, M. T., Ports, K. A., Klevens, J., & Leeb, R. (2018). Intergenerational continuity in adverse childhood experiences and rural community environments. American Journal of Public Health, 108(9), 1148-1152. https://doi.org/10.2105/AJPH.2018.304598 ACES AND MATERNAL EDUCATION 24 Schofield, T. J., Lee, R. D., & Merrick, M. T. (2013). Safe, stable, nurturing relationships as a moderator of intergenerational continuity of child maltreatment: A meta-analysis. Journal of Adolescent Health, 53(4, Supplement), S32-S38. https://doi.org/10.1016/j.jadohealth.2013.05.004 Steele, H., Bate, J., Steele, M., Dube, S. R., Danskin, K., Knafo, H., … Murphy, A. (2016). Adverse childhood experiences, poverty, and parenting stress. Canadian Journal of Behavioural Science/Revue Canadienne Des Sciences Du Comportement, 48(1), 32-38. http://dx.doi.org.ezproxy1.lib.asu.edu/10.1037/cbs0000034 Stetler, C. B. (2001). Updating the Stetler model of research utilization to facilitate evidencebased practice. Nursing Outlook, 49(6), 272-279. https://doi.org/10.1067/mno.2001.120517 Traub, F., & Boynton-Jarrett, R. (2017). Modifiable resilience factors to childhood adversity for clinical pediatric practice. Pediatrics, 139(5), 1-14. https://doi.org/10.1542/peds.2016-2569 Wade, R., Shea, J. A., Rubin, D., & Wood, J. (2014). Adverse childhood experiences of low-income urban youth. Pediatrics, 134(1), 13–20. https://doi.org/10.1542/peds.20132475 Woods-Jaeger, B. A., Cho, B., Sexton, C. C., Slagel, L., & Goggin, K. (2018). Promoting resilience: Breaking the intergenerational cycle of adverse childhood experiences. Health Education & Behavior, 45(5), 772–780. https://doi.org/10.1177/1090198117752785 Ziv, Y., Sofri, I., Capps Umphlet, K. L., Olarte, S., & Venza, J. (2018). Children and caregivers’ exposure to adverse childhood experiences (ACES): Association with children’s and caregivers’ psychological outcomes in a therapeutic preschool program. International ACES AND MATERNAL EDUCATION Journal of Environmental Research and Public Health, 15(4). https://doi.org/10.3390/ijerph15040646 25 ACES AND MATERNAL EDUCATION 26 Appendix A Table 1 Evaluation Table Citation Theory/ Conceptual Framework Design/ Method Sample/ Setting Major Variables & Definitions Measurement/ Instrumentatio n Data Analysis Findings/ Results Muzik et al., (2015). Mom power: Preliminary outcomes of a group intervention to improve mental health and parenting among high-risk mothers. Rooted in Attachment Theory Design: NRNCT (pre and posttest pilot study) N= 99 IV: MP DV1: mental health (depression & PTSD) DV1: PDSS – SN 0.78; SP 0.99 NWS-PTSD – SN 0.99; SP 0.79 Demographic s and baseline characteristics evaluated using chisquared & independent t tests DV1: Significant reduction of symptoms & diagnosis: Also incorporated: Demographics : Mean age: 24 Gender: 99 F Some college or less: 85.2 % Income > $15,000/year: 67.8% Single: 62.8% Interpersonal TE: 72.7% Environmental TE: 98% LOE; Decision for practice/ application to practice LOE: IV Strengths: high retention, effective multi-modal intervention. Purpose: Examine the Depression Self-Care effectiveness (p =.003; p DV2: Theory; of a parenting = .029) DV2: Weaknesses: Trauma multimodal competence CHQ & WMCI Paired t tests PTSD (p = Pilot study, Theory; intervention (helplessnes used within and .006; p = small sample, Social (MP) on s& interviews McNemar’s .013) & no CG. Learning maternal reflectivity) ICC: tests used for Funding: State of Theory mental health Parenting Pre-Post DV2: For Feasibility: Michigan and parenting reflectivity – intervention MP Home visits DV3: Department of outcomes for engagement 0.91 completers and 13 Community high-risk in treatment Parenting Interviews parenting individual Health, mothers with helplessness – coded – twohelplessness sessions may mental health DV4: IS 0.62 & limit this Key: ACE- adverse childhood experience; ANOVA- analysis of variance; APQ-S- Alabama Parenting Questionnaire-Short Form; AT- Attachment Theory; BDI-II- Beck Depression Inventory; BERS2- Behavioral and Emotional Rating Scale, 2nd Edition; CDSR- Cochrane Database of Systematic Reviews; CENTRAL- Cochrane Central Register of Controlled Trials; CG- control group; CHQ- Caregiving Helplessness Questionnaire; CT- Coercion Theory; Demosdemographics; DS- database search; DV- dependent variable; EC- exclusion criteria; ECBI- Eyberg Child Behavior Scale; F- female; FP7- Seventh Framework Programme; GAIN-SS- Global Appraisal of Individual Needs; HS- high school; IC- inclusion criteria; ICC-intraclass correlation coefficient; IS- intervention satisfaction; IV- independent variable; LOE- level of evidence; M- mean age; MA- meta-analysis; MCAR- Little’s missing at random test; MP- mom power; MSPSS- Multidimensional Scale of Perceived Social Support; n- number of participants (if SR) or number of participants in subset; N- number of studies (if SR) or participants in study; NHA- nurtured heart approach; NIH- National Institutes of Health registry of clinical trials; NRNCT- non-randomized non-controlled trial; NRCT- non-randomized controlled trial; NS- not stated; NSig- not significant; NWS-PTSD- National Women's Study PTSD Module; PARYC- Parenting Young Children Scale; PCCTS- Parent-Child Conflict Tactics Scale; PDSS- postpartum depression screening scale; PI- parenting intervention; PP- parenting program; PPI- parent practices interview; PRQ- Parenting Relationship Questionnaire; PSI- Parenting Stress Index; PSOC- Parenting Sense of Competence Scale; PTSD- post traumatic stress disorder; RCT- randomized control trial; SDQ- Strength and Difficulties Questionnaire; SLT- Social Learning Theory; SNsensitivity; SOCS- Sinovuyo Observational Coding System; SP- specificity; SR- systematic review; SS- search string; TE- trauma exposure; VIPP-SD- Videofeedback Intervention to promote Positive Parenting and Sensitive Discipline; WHO- World Health Organization registry of clinical trials; WMCI- Working Model of the Child Interview ACES AND MATERNAL EDUCATION 27 Table 1 Evaluation Table Citation University of Michigan, Michigan Institute for Clinical & Health Research, Robert Wood Johnson Health & Society Program Bias: None Country: USA Theory/ Conceptual Framework Design/ Method Sample/ Setting challenges and social risk factors. Setting: Mothers in the community. IC: Mother seeking parenting counseling. Has child infant to 5 years. Otherwise not stringent. EC: illicit substance use, acute suicidality, and psychosis. Major Variables & Definitions Measurement/ Instrumentatio n Definitions: DV3: coded as frequency of attendance MP: 13week (10 group sessions and 3 individual sessions) focused on promoting secure attachment between mother and child, and maternal self-care. DV4: 28 item survey on IS using 5 point Likert scale Initial interviews for demographic info Data Analysis Findings/ Results tailed statistics reflectivity improved significantly (p = .023; p = .021) IS & engagement evaluated using frequency counts DV3: 72% completed MP LOE; Decision for practice/ application to practice intervention due to time and availability. Utility to the PICOT: Addresses every part of the PICOT at this time. DV4: IS 85% strongly agreed; 15% agreed Key: ACE- adverse childhood experience; ANOVA- analysis of variance; APQ-S- Alabama Parenting Questionnaire-Short Form; AT- Attachment Theory; BDI-II- Beck Depression Inventory; BERS2- Behavioral and Emotional Rating Scale, 2nd Edition; CDSR- Cochrane Database of Systematic Reviews; CENTRAL- Cochrane Central Register of Controlled Trials; CG- control group; CHQ- Caregiving Helplessness Questionnaire; CT- Coercion Theory; Demosdemographics; DS- database search; DV- dependent variable; EC- exclusion criteria; ECBI- Eyberg Child Behavior Scale; F- female; FP7- Seventh Framework Programme; GAIN-SS- Global Appraisal of Individual Needs; HS- high school; IC- inclusion criteria; ICC-intraclass correlation coefficient; IS- intervention satisfaction; IV- independent variable; LOE- level of evidence; M- mean age; MA- meta-analysis; MCAR- Little’s missing at random test; MP- mom power; MSPSS- Multidimensional Scale of Perceived Social Support; n- number of participants (if SR) or number of participants in subset; N- number of studies (if SR) or participants in study; NHA- nurtured heart approach; NIH- National Institutes of Health registry of clinical trials; NRNCT- non-randomized non-controlled trial; NRCT- non-randomized controlled trial; NS- not stated; NSig- not significant; NWS-PTSD- National Women's Study PTSD Module; PARYC- Parenting Young Children Scale; PCCTS- Parent-Child Conflict Tactics Scale; PDSS- postpartum depression screening scale; PI- parenting intervention; PP- parenting program; PPI- parent practices interview; PRQ- Parenting Relationship Questionnaire; PSI- Parenting Stress Index; PSOC- Parenting Sense of Competence Scale; PTSD- post traumatic stress disorder; RCT- randomized control trial; SDQ- Strength and Difficulties Questionnaire; SLT- Social Learning Theory; SNsensitivity; SOCS- Sinovuyo Observational Coding System; SP- specificity; SR- systematic review; SS- search string; TE- trauma exposure; VIPP-SD- Videofeedback Intervention to promote Positive Parenting and Sensitive Discipline; WHO- World Health Organization registry of clinical trials; WMCI- Working Model of the Child Interview ACES AND MATERNAL EDUCATION 28 Table 1 Evaluation Table Citation Theory/ Conceptual Framework Design/ Method Sample/ Setting Major Variables & Definitions Measurement/ Instrumentatio n Data Analysis Findings/ Results LOE; Decision for practice/ application to practice Purewal et al., (2018). Ameliorating the biological impacts of childhood adversity: A review of intervention programs NS Design: SR of RCTs N= 40 n= 34-461 Biological markers DS: PubMed, CINAHL, PsychInfo, Sociological Abstracts, NIH, WHO, CENTRAL, and CDSR Quality Assessment of Evidence – primary sources across medical, health, psychology, and sociology databases. Consistency across samples: 3 key elements to PIs were: strong parenting skills, earlier intervention placement, and greater intervention engagement. LOE: I Purpose: Explore and evaluate effectiveness of PIs that have addressed biological markers and physical health outcomes in children with ACEs. IV: Childhood ACE intervention s Funding: JPB Foundation [grant # 369] Bias: none found Country: USA IC: 2007-2017, ACEs, intervention during childhood, biological health DV: biological health outcomes Strengths: High LOE, published in past year and reviewed evidence from past 12 years. Weaknesses: Lack of physiological baseline data, and high attrition in some studies. Some terms may have not Key: ACE- adverse childhood experience; ANOVA- analysis of variance; APQ-S- Alabama Parenting Questionnaire-Short Form; AT- Attachment Theory; BDI-II- Beck Depression Inventory; BERS2- Behavioral and Emotional Rating Scale, 2nd Edition; CDSR- Cochrane Database of Systematic Reviews; CENTRAL- Cochrane Central Register of Controlled Trials; CG- control group; CHQ- Caregiving Helplessness Questionnaire; CT- Coercion Theory; Demosdemographics; DS- database search; DV- dependent variable; EC- exclusion criteria; ECBI- Eyberg Child Behavior Scale; F- female; FP7- Seventh Framework Programme; GAIN-SS- Global Appraisal of Individual Needs; HS- high school; IC- inclusion criteria; ICC-intraclass correlation coefficient; IS- intervention satisfaction; IV- independent variable; LOE- level of evidence; M- mean age; MA- meta-analysis; MCAR- Little’s missing at random test; MP- mom power; MSPSS- Multidimensional Scale of Perceived Social Support; n- number of participants (if SR) or number of participants in subset; N- number of studies (if SR) or participants in study; NHA- nurtured heart approach; NIH- National Institutes of Health registry of clinical trials; NRNCT- non-randomized non-controlled trial; NRCT- non-randomized controlled trial; NS- not stated; NSig- not significant; NWS-PTSD- National Women's Study PTSD Module; PARYC- Parenting Young Children Scale; PCCTS- Parent-Child Conflict Tactics Scale; PDSS- postpartum depression screening scale; PI- parenting intervention; PP- parenting program; PPI- parent practices interview; PRQ- Parenting Relationship Questionnaire; PSI- Parenting Stress Index; PSOC- Parenting Sense of Competence Scale; PTSD- post traumatic stress disorder; RCT- randomized control trial; SDQ- Strength and Difficulties Questionnaire; SLT- Social Learning Theory; SNsensitivity; SOCS- Sinovuyo Observational Coding System; SP- specificity; SR- systematic review; SS- search string; TE- trauma exposure; VIPP-SD- Videofeedback Intervention to promote Positive Parenting and Sensitive Discipline; WHO- World Health Organization registry of clinical trials; WMCI- Working Model of the Child Interview ACES AND MATERNAL EDUCATION 29 Table 1 Evaluation Table Citation Theory/ Conceptual Framework Design/ Method Sample/ Setting measurement, RCT. Major Variables & Definitions Measurement/ Instrumentatio n Data Analysis Findings/ Results LOE; Decision for practice/ application to practice been accounted for. Feasibility: Results of this SR reveal there is evidencesupporting effectiveness of early intervention for ACEs. Utility to the PICOT: Addresses different intervention relevant to PICOT. Key: ACE- adverse childhood experience; ANOVA- analysis of variance; APQ-S- Alabama Parenting Questionnaire-Short Form; AT- Attachment Theory; BDI-II- Beck Depression Inventory; BERS2- Behavioral and Emotional Rating Scale, 2nd Edition; CDSR- Cochrane Database of Systematic Reviews; CENTRAL- Cochrane Central Register of Controlled Trials; CG- control group; CHQ- Caregiving Helplessness Questionnaire; CT- Coercion Theory; Demosdemographics; DS- database search; DV- dependent variable; EC- exclusion criteria; ECBI- Eyberg Child Behavior Scale; F- female; FP7- Seventh Framework Programme; GAIN-SS- Global Appraisal of Individual Needs; HS- high school; IC- inclusion criteria; ICC-intraclass correlation coefficient; IS- intervention satisfaction; IV- independent variable; LOE- level of evidence; M- mean age; MA- meta-analysis; MCAR- Little’s missing at random test; MP- mom power; MSPSS- Multidimensional Scale of Perceived Social Support; n- number of participants (if SR) or number of participants in subset; N- number of studies (if SR) or participants in study; NHA- nurtured heart approach; NIH- National Institutes of Health registry of clinical trials; NRNCT- non-randomized non-controlled trial; NRCT- non-randomized controlled trial; NS- not stated; NSig- not significant; NWS-PTSD- National Women's Study PTSD Module; PARYC- Parenting Young Children Scale; PCCTS- Parent-Child Conflict Tactics Scale; PDSS- postpartum depression screening scale; PI- parenting intervention; PP- parenting program; PPI- parent practices interview; PRQ- Parenting Relationship Questionnaire; PSI- Parenting Stress Index; PSOC- Parenting Sense of Competence Scale; PTSD- post traumatic stress disorder; RCT- randomized control trial; SDQ- Strength and Difficulties Questionnaire; SLT- Social Learning Theory; SNsensitivity; SOCS- Sinovuyo Observational Coding System; SP- specificity; SR- systematic review; SS- search string; TE- trauma exposure; VIPP-SD- Videofeedback Intervention to promote Positive Parenting and Sensitive Discipline; WHO- World Health Organization registry of clinical trials; WMCI- Working Model of the Child Interview ACES AND MATERNAL EDUCATION 30 Table 1 Evaluation Table Citation Theory/ Conceptual Framework Design/ Method Sample/ Setting Major Variables & Definitions Measurement/ Instrumentatio n Data Analysis Findings/ Results LOE; Decision for practice/ application to practice Lindstrom Johnson et al., (2018). A metaanalysis of parenting practices and child psychosocial outcomes in traumainformed parenting interventions after violence exposure. Family Systems Theory Design: MA N= 21 n= 21-203 IV: PIs Child Behavior Checklist; Parenting Stress Index Cohen’s d Heterogeneity statistic, Q Trim and Fill procedure Rosenthal’s failsafe n DV1: k (n) 12(402) d 0.72 SE 0.16 95% CI 0.43, 1.00 Q 163.99 LOE: I Funding: NS Purpose: synthesize literature on trauma informed PIs and the effect on parenting and child outcomes. DS: PsychInfo & PubMed SS: ab (parent*) AND ab (violence OR conflict OR trauma) AND if (intervention* OR prevention* OR evaluation*) DV1: positive parenting practices DV2: negative parenting practices DV3: parenting stress DV4: children’s internalizing problems DV2: k (n) 3(49) d 0.63 SE 0.17 95% CI 0.13, 1.36 Q 4.52 DV3: k (n) 4(104) d 0.24 SE 0.12 95% CI Strengths: High LOE, validity tests performed, published within last year. Weaknesses: only 21 articles met inclusion, some studies lacked demographics & length. Key: ACE- adverse childhood experience; ANOVA- analysis of variance; APQ-S- Alabama Parenting Questionnaire-Short Form; AT- Attachment Theory; BDI-II- Beck Depression Inventory; BERS2- Behavioral and Emotional Rating Scale, 2nd Edition; CDSR- Cochrane Database of Systematic Reviews; CENTRAL- Cochrane Central Register of Controlled Trials; CG- control group; CHQ- Caregiving Helplessness Questionnaire; CT- Coercion Theory; Demosdemographics; DS- database search; DV- dependent variable; EC- exclusion criteria; ECBI- Eyberg Child Behavior Scale; F- female; FP7- Seventh Framework Programme; GAIN-SS- Global Appraisal of Individual Needs; HS- high school; IC- inclusion criteria; ICC-intraclass correlation coefficient; IS- intervention satisfaction; IV- independent variable; LOE- level of evidence; M- mean age; MA- meta-analysis; MCAR- Little’s missing at random test; MP- mom power; MSPSS- Multidimensional Scale of Perceived Social Support; n- number of participants (if SR) or number of participants in subset; N- number of studies (if SR) or participants in study; NHA- nurtured heart approach; NIH- National Institutes of Health registry of clinical trials; NRNCT- non-randomized non-controlled trial; NRCT- non-randomized controlled trial; NS- not stated; NSig- not significant; NWS-PTSD- National Women's Study PTSD Module; PARYC- Parenting Young Children Scale; PCCTS- Parent-Child Conflict Tactics Scale; PDSS- postpartum depression screening scale; PI- parenting intervention; PP- parenting program; PPI- parent practices interview; PRQ- Parenting Relationship Questionnaire; PSI- Parenting Stress Index; PSOC- Parenting Sense of Competence Scale; PTSD- post traumatic stress disorder; RCT- randomized control trial; SDQ- Strength and Difficulties Questionnaire; SLT- Social Learning Theory; SNsensitivity; SOCS- Sinovuyo Observational Coding System; SP- specificity; SR- systematic review; SS- search string; TE- trauma exposure; VIPP-SD- Videofeedback Intervention to promote Positive Parenting and Sensitive Discipline; WHO- World Health Organization registry of clinical trials; WMCI- Working Model of the Child Interview ACES AND MATERNAL EDUCATION 31 Table 1 Evaluation Table Citation Bias: None identified Country: USA Theory/ Conceptual Framework Design/ Method Sample/ Setting Major Variables & Definitions IC: parent or family based intervention for children with ACE, parent focused intervention, ACEs related to conflict & violence. Empirical & quantitative studies only. Mean age 5-18. DV5: children’s externalizin g problems DV6: trauma symptoms EC: interventions for only children, other forms of trauma, Measurement/ Instrumentatio n Data Analysis Findings/ Results -0.03, 0.49 Q 4.61 DV4: k (n) 16(802) d 0.59 SE 0.08 95% CI 0.43, 0.74 Q 68.58 DV5: k (n) 17(860) d 0.48 SE 0.05 95% CI 0.34, 0.62 Q 58.81 DV6: k (n) 9(479) d 0.56 SE 0.15 95% CI LOE; Decision for practice/ application to practice Variability in assessment tools. Feasibility: Reveals trauma focused PIs improve parent and child outcomes. Utility to the PICOT: Applicable to all aspects of the PICOT at this time. Key: ACE- adverse childhood experience; ANOVA- analysis of variance; APQ-S- Alabama Parenting Questionnaire-Short Form; AT- Attachment Theory; BDI-II- Beck Depression Inventory; BERS2- Behavioral and Emotional Rating Scale, 2nd Edition; CDSR- Cochrane Database of Systematic Reviews; CENTRAL- Cochrane Central Register of Controlled Trials; CG- control group; CHQ- Caregiving Helplessness Questionnaire; CT- Coercion Theory; Demosdemographics; DS- database search; DV- dependent variable; EC- exclusion criteria; ECBI- Eyberg Child Behavior Scale; F- female; FP7- Seventh Framework Programme; GAIN-SS- Global Appraisal of Individual Needs; HS- high school; IC- inclusion criteria; ICC-intraclass correlation coefficient; IS- intervention satisfaction; IV- independent variable; LOE- level of evidence; M- mean age; MA- meta-analysis; MCAR- Little’s missing at random test; MP- mom power; MSPSS- Multidimensional Scale of Perceived Social Support; n- number of participants (if SR) or number of participants in subset; N- number of studies (if SR) or participants in study; NHA- nurtured heart approach; NIH- National Institutes of Health registry of clinical trials; NRNCT- non-randomized non-controlled trial; NRCT- non-randomized controlled trial; NS- not stated; NSig- not significant; NWS-PTSD- National Women's Study PTSD Module; PARYC- Parenting Young Children Scale; PCCTS- Parent-Child Conflict Tactics Scale; PDSS- postpartum depression screening scale; PI- parenting intervention; PP- parenting program; PPI- parent practices interview; PRQ- Parenting Relationship Questionnaire; PSI- Parenting Stress Index; PSOC- Parenting Sense of Competence Scale; PTSD- post traumatic stress disorder; RCT- randomized control trial; SDQ- Strength and Difficulties Questionnaire; SLT- Social Learning Theory; SNsensitivity; SOCS- Sinovuyo Observational Coding System; SP- specificity; SR- systematic review; SS- search string; TE- trauma exposure; VIPP-SD- Videofeedback Intervention to promote Positive Parenting and Sensitive Discipline; WHO- World Health Organization registry of clinical trials; WMCI- Working Model of the Child Interview ACES AND MATERNAL EDUCATION 32 Table 1 Evaluation Table Citation Lachman et al., (2017). Randomized controlled trial of a parenting program to reduce the risk of child maltreatment in South Africa. Funding: Ilifa Labantwana Fund, University of Oxford-UK, South African National Lottery Distribution Trust Theory/ Conceptual Framework AT & SLT Inferred Design/ Method Design: RCT Purpose: examine the effect of a PP on reducing the risk of child maltreatment in low-income families with children aged 3-8 years Sample/ Setting intervention following divorce. N= 68 IG= 34 CG= 32 Demos: parentchild dyads; Parents- M: 34, 100% F, 77% single, 74% completed HS, 94% unemployed Children- M: 5, 50% F, 59% with biological parent. Family characteristics74% with Major Variables & Definitions Measurement/ Instrumentatio n Data Analysis Findings/ Results LOE; Decision for practice/ application to practice 0.36, 0.76 Q 128.93 IV1: PP DV1: Harsh parenting – parent report DV2: Positive parenting – parent report DV3: Child behavior problems – parent report DV4: Observed parenting and child behavior DV1: PCCTS DV2: PARYC DV3: ECBI DV4: SOCS DV5: PSI parenting distress subscale DV6: BDI-II DV7: MSPSS ICC, ANOVA, Chi-square, Cohen’s d, effect size of 0.2=small, 0.5=moderate , & 0.8 or higher=large DV1: NSig DV2:p< 0.01 DV3: NSig DV4:p< 0.05 DV5: NSig DV6: NSig DV7: NSig LOE: II Strengths: high level of recruitment and retention, & strong reliability of measures. Weakness: small sample size, lack of male caregivers in sample. Key: ACE- adverse childhood experience; ANOVA- analysis of variance; APQ-S- Alabama Parenting Questionnaire-Short Form; AT- Attachment Theory; BDI-II- Beck Depression Inventory; BERS2- Behavioral and Emotional Rating Scale, 2nd Edition; CDSR- Cochrane Database of Systematic Reviews; CENTRAL- Cochrane Central Register of Controlled Trials; CG- control group; CHQ- Caregiving Helplessness Questionnaire; CT- Coercion Theory; Demosdemographics; DS- database search; DV- dependent variable; EC- exclusion criteria; ECBI- Eyberg Child Behavior Scale; F- female; FP7- Seventh Framework Programme; GAIN-SS- Global Appraisal of Individual Needs; HS- high school; IC- inclusion criteria; ICC-intraclass correlation coefficient; IS- intervention satisfaction; IV- independent variable; LOE- level of evidence; M- mean age; MA- meta-analysis; MCAR- Little’s missing at random test; MP- mom power; MSPSS- Multidimensional Scale of Perceived Social Support; n- number of participants (if SR) or number of participants in subset; N- number of studies (if SR) or participants in study; NHA- nurtured heart approach; NIH- National Institutes of Health registry of clinical trials; NRNCT- non-randomized non-controlled trial; NRCT- non-randomized controlled trial; NS- not stated; NSig- not significant; NWS-PTSD- National Women's Study PTSD Module; PARYC- Parenting Young Children Scale; PCCTS- Parent-Child Conflict Tactics Scale; PDSS- postpartum depression screening scale; PI- parenting intervention; PP- parenting program; PPI- parent practices interview; PRQ- Parenting Relationship Questionnaire; PSI- Parenting Stress Index; PSOC- Parenting Sense of Competence Scale; PTSD- post traumatic stress disorder; RCT- randomized control trial; SDQ- Strength and Difficulties Questionnaire; SLT- Social Learning Theory; SNsensitivity; SOCS- Sinovuyo Observational Coding System; SP- specificity; SR- systematic review; SS- search string; TE- trauma exposure; VIPP-SD- Videofeedback Intervention to promote Positive Parenting and Sensitive Discipline; WHO- World Health Organization registry of clinical trials; WMCI- Working Model of the Child Interview ACES AND MATERNAL EDUCATION 33 Table 1 Evaluation Table Citation Fund, European Union (FP7) Bias: None identified Country: South Africa Theory/ Conceptual Framework Design/ Method Sample/ Setting informal housing, Avg household size 5.56 Setting: lowincome suburb in Cape Town, South Africa characterized by high levels of poverty, intimate partner violence, substance abuse, and HIV prevalence Major Variables & Definitions Secondary outcomes: DV5: parenting stress DV6: parental depression DV7: perceived social support Measurement/ Instrumentatio n Data Analysis Findings/ Results LOE; Decision for practice/ application to practice Feasibility: unable to use parent child dyads for project, but gives insight on parent needs. Utility to PICOT: applicable to intervention and population. Exclusion: participants or children who Key: ACE- adverse childhood experience; ANOVA- analysis of variance; APQ-S- Alabama Parenting Questionnaire-Short Form; AT- Attachment Theory; BDI-II- Beck Depression Inventory; BERS2- Behavioral and Emotional Rating Scale, 2nd Edition; CDSR- Cochrane Database of Systematic Reviews; CENTRAL- Cochrane Central Register of Controlled Trials; CG- control group; CHQ- Caregiving Helplessness Questionnaire; CT- Coercion Theory; Demosdemographics; DS- database search; DV- dependent variable; EC- exclusion criteria; ECBI- Eyberg Child Behavior Scale; F- female; FP7- Seventh Framework Programme; GAIN-SS- Global Appraisal of Individual Needs; HS- high school; IC- inclusion criteria; ICC-intraclass correlation coefficient; IS- intervention satisfaction; IV- independent variable; LOE- level of evidence; M- mean age; MA- meta-analysis; MCAR- Little’s missing at random test; MP- mom power; MSPSS- Multidimensional Scale of Perceived Social Support; n- number of participants (if SR) or number of participants in subset; N- number of studies (if SR) or participants in study; NHA- nurtured heart approach; NIH- National Institutes of Health registry of clinical trials; NRNCT- non-randomized non-controlled trial; NRCT- non-randomized controlled trial; NS- not stated; NSig- not significant; NWS-PTSD- National Women's Study PTSD Module; PARYC- Parenting Young Children Scale; PCCTS- Parent-Child Conflict Tactics Scale; PDSS- postpartum depression screening scale; PI- parenting intervention; PP- parenting program; PPI- parent practices interview; PRQ- Parenting Relationship Questionnaire; PSI- Parenting Stress Index; PSOC- Parenting Sense of Competence Scale; PTSD- post traumatic stress disorder; RCT- randomized control trial; SDQ- Strength and Difficulties Questionnaire; SLT- Social Learning Theory; SNsensitivity; SOCS- Sinovuyo Observational Coding System; SP- specificity; SR- systematic review; SS- search string; TE- trauma exposure; VIPP-SD- Videofeedback Intervention to promote Positive Parenting and Sensitive Discipline; WHO- World Health Organization registry of clinical trials; WMCI- Working Model of the Child Interview ACES AND MATERNAL EDUCATION 34 Table 1 Evaluation Table Citation Theory/ Conceptual Framework Design/ Method Sample/ Setting Major Variables & Definitions Measurement/ Instrumentatio n Data Analysis Findings/ Results LOE; Decision for practice/ application to practice Major Variables & Definitions Measurement/ Instrumentatio n Data Analysis Findings/ Results LOE; Decision for practice/ application to practice exhibited acute mental health problems or severe disabilities Citation Theory/ Conceptual Framework Design/ Method Attrition: Self-report data = 3% lost to follow-up Observational assessment = 12% baseline & 10% post-test Sample/ Setting Key: ACE- adverse childhood experience; ANOVA- analysis of variance; APQ-S- Alabama Parenting Questionnaire-Short Form; AT- Attachment Theory; BDI-II- Beck Depression Inventory; BERS2- Behavioral and Emotional Rating Scale, 2nd Edition; CDSR- Cochrane Database of Systematic Reviews; CENTRAL- Cochrane Central Register of Controlled Trials; CG- control group; CHQ- Caregiving Helplessness Questionnaire; CT- Coercion Theory; Demosdemographics; DS- database search; DV- dependent variable; EC- exclusion criteria; ECBI- Eyberg Child Behavior Scale; F- female; FP7- Seventh Framework Programme; GAIN-SS- Global Appraisal of Individual Needs; HS- high school; IC- inclusion criteria; ICC-intraclass correlation coefficient; IS- intervention satisfaction; IV- independent variable; LOE- level of evidence; M- mean age; MA- meta-analysis; MCAR- Little’s missing at random test; MP- mom power; MSPSS- Multidimensional Scale of Perceived Social Support; n- number of participants (if SR) or number of participants in subset; N- number of studies (if SR) or participants in study; NHA- nurtured heart approach; NIH- National Institutes of Health registry of clinical trials; NRNCT- non-randomized non-controlled trial; NRCT- non-randomized controlled trial; NS- not stated; NSig- not significant; NWS-PTSD- National Women's Study PTSD Module; PARYC- Parenting Young Children Scale; PCCTS- Parent-Child Conflict Tactics Scale; PDSS- postpartum depression screening scale; PI- parenting intervention; PP- parenting program; PPI- parent practices interview; PRQ- Parenting Relationship Questionnaire; PSI- Parenting Stress Index; PSOC- Parenting Sense of Competence Scale; PTSD- post traumatic stress disorder; RCT- randomized control trial; SDQ- Strength and Difficulties Questionnaire; SLT- Social Learning Theory; SNsensitivity; SOCS- Sinovuyo Observational Coding System; SP- specificity; SR- systematic review; SS- search string; TE- trauma exposure; VIPP-SD- Videofeedback Intervention to promote Positive Parenting and Sensitive Discipline; WHO- World Health Organization registry of clinical trials; WMCI- Working Model of the Child Interview ACES AND MATERNAL EDUCATION 35 Table 1 Evaluation Table Citation Theory/ Conceptual Framework Design/ Method Sample/ Setting Major Variables & Definitions Measurement/ Instrumentatio n Data Analysis Findings/ Results Brennan et al., (2016). A nonrandomized evaluation of a brief nurtured heart approach parent training program. Developmental Theory Design: NRCT N= 416 IG= 324 CG= 92 IV1: NHA PP DV1: PRQ DV2: The Parent Discipline Scales – subscale DV3: BERS2 DV4: 2 item questionnaire ANOVA, Cohens d, coding DV1: frustration p <.001, Confidence p <.001 DV2: tangible reward p= .385, positive attention p=.003, time out p= .180,yell or scold p<.001, negativity p<.001 DV3: p<.001 Funding: NS Bias: None identified Country: USA Purpose: to provide an initial test of the effectiveness of NHA in a community sample. Demos: 74% mothers, 65% parents most concerned about their son, 63% of parents’ children were between ages of 4 and 10. Setting: midsized Midwestern city & population is ~ 90 % Caucasian. DV1: parent well-being DV2: parent practices DV3: child interpersona l strengths DV4: qualitative parent feedback LOE; Decision for practice/ application to practice LOE: IV Strengths: adequate sample size, use of comparison group, and nationally utilized, reliable measures. Weakness: no randomization, no explicit curriculum, all data collected through parent reports. Key: ACE- adverse childhood experience; ANOVA- analysis of variance; APQ-S- Alabama Parenting Questionnaire-Short Form; AT- Attachment Theory; BDI-II- Beck Depression Inventory; BERS2- Behavioral and Emotional Rating Scale, 2nd Edition; CDSR- Cochrane Database of Systematic Reviews; CENTRAL- Cochrane Central Register of Controlled Trials; CG- control group; CHQ- Caregiving Helplessness Questionnaire; CT- Coercion Theory; Demosdemographics; DS- database search; DV- dependent variable; EC- exclusion criteria; ECBI- Eyberg Child Behavior Scale; F- female; FP7- Seventh Framework Programme; GAIN-SS- Global Appraisal of Individual Needs; HS- high school; IC- inclusion criteria; ICC-intraclass correlation coefficient; IS- intervention satisfaction; IV- independent variable; LOE- level of evidence; M- mean age; MA- meta-analysis; MCAR- Little’s missing at random test; MP- mom power; MSPSS- Multidimensional Scale of Perceived Social Support; n- number of participants (if SR) or number of participants in subset; N- number of studies (if SR) or participants in study; NHA- nurtured heart approach; NIH- National Institutes of Health registry of clinical trials; NRNCT- non-randomized non-controlled trial; NRCT- non-randomized controlled trial; NS- not stated; NSig- not significant; NWS-PTSD- National Women's Study PTSD Module; PARYC- Parenting Young Children Scale; PCCTS- Parent-Child Conflict Tactics Scale; PDSS- postpartum depression screening scale; PI- parenting intervention; PP- parenting program; PPI- parent practices interview; PRQ- Parenting Relationship Questionnaire; PSI- Parenting Stress Index; PSOC- Parenting Sense of Competence Scale; PTSD- post traumatic stress disorder; RCT- randomized control trial; SDQ- Strength and Difficulties Questionnaire; SLT- Social Learning Theory; SNsensitivity; SOCS- Sinovuyo Observational Coding System; SP- specificity; SR- systematic review; SS- search string; TE- trauma exposure; VIPP-SD- Videofeedback Intervention to promote Positive Parenting and Sensitive Discipline; WHO- World Health Organization registry of clinical trials; WMCI- Working Model of the Child Interview ACES AND MATERNAL EDUCATION 36 Table 1 Evaluation Table Citation Theory/ Conceptual Framework Design/ Method Sample/ Setting Major Variables & Definitions Measurement/ Instrumentatio n Data Analysis DV4: major themes: desirable changes in attitudes, beliefs, or perspectives , desirable change in behaviors, increased parental confidence Exclusion: NS Attrition: 14% Citation Theory/ Conceptual Framework Design/ Method Sample/ Setting Findings/ Results Major Variables & Definitions Measurement/ Instrumentatio n Data Analysis Findings/ Results LOE; Decision for practice/ application to practice Feasibility: 5 sessions of 7.5 hours total is doable at a community residential facility. Utility to PICOT: Good insight on PI program design and results. LOE; Decision for practice/ application to practice Key: ACE- adverse childhood experience; ANOVA- analysis of variance; APQ-S- Alabama Parenting Questionnaire-Short Form; AT- Attachment Theory; BDI-II- Beck Depression Inventory; BERS2- Behavioral and Emotional Rating Scale, 2nd Edition; CDSR- Cochrane Database of Systematic Reviews; CENTRAL- Cochrane Central Register of Controlled Trials; CG- control group; CHQ- Caregiving Helplessness Questionnaire; CT- Coercion Theory; Demosdemographics; DS- database search; DV- dependent variable; EC- exclusion criteria; ECBI- Eyberg Child Behavior Scale; F- female; FP7- Seventh Framework Programme; GAIN-SS- Global Appraisal of Individual Needs; HS- high school; IC- inclusion criteria; ICC-intraclass correlation coefficient; IS- intervention satisfaction; IV- independent variable; LOE- level of evidence; M- mean age; MA- meta-analysis; MCAR- Little’s missing at random test; MP- mom power; MSPSS- Multidimensional Scale of Perceived Social Support; n- number of participants (if SR) or number of participants in subset; N- number of studies (if SR) or participants in study; NHA- nurtured heart approach; NIH- National Institutes of Health registry of clinical trials; NRNCT- non-randomized non-controlled trial; NRCT- non-randomized controlled trial; NS- not stated; NSig- not significant; NWS-PTSD- National Women's Study PTSD Module; PARYC- Parenting Young Children Scale; PCCTS- Parent-Child Conflict Tactics Scale; PDSS- postpartum depression screening scale; PI- parenting intervention; PP- parenting program; PPI- parent practices interview; PRQ- Parenting Relationship Questionnaire; PSI- Parenting Stress Index; PSOC- Parenting Sense of Competence Scale; PTSD- post traumatic stress disorder; RCT- randomized control trial; SDQ- Strength and Difficulties Questionnaire; SLT- Social Learning Theory; SNsensitivity; SOCS- Sinovuyo Observational Coding System; SP- specificity; SR- systematic review; SS- search string; TE- trauma exposure; VIPP-SD- Videofeedback Intervention to promote Positive Parenting and Sensitive Discipline; WHO- World Health Organization registry of clinical trials; WMCI- Working Model of the Child Interview ACES AND MATERNAL EDUCATION 37 Table 1 Evaluation Table Citation Theory/ Conceptual Framework Design/ Method Sample/ Setting Major Variables & Definitions Measurement/ Instrumentatio n Data Analysis Findings/ Results Pereira et al., (2014). Decreasing harsh discipline in mothers at risk for maltreatment: A randomized control trial. AT; CT Design: RCT Pre/posttest N= 44 IG= 22 CG= 22 IV1: VIPPSD Pre & posttest observations t test, chisquare, ANOVA DV1: harsh discipline DV2: parenting stress Daily Hassles Questionnaire with The Parenting Stress subscale Found that VIPP-SD decreases maternal harsh discipline only under selfperceived parenting stress; experimenta l Condition + time + parenting stress was significant, F (1, 39) = 5.84, p < .05. Funding: Portuguese Foundation for Science and Technology Bias: None identified Country: Portugal Purpose: effectiveness of VIPP-SD in decreasing harsh discipline in severely deprived mothers of 1to 4-year-old children screened for their problematic caregiving environment Demos: mother (M= 30 years) child (M= 28 months) dyads, mother, children = 50 F, mothers 65% married/in relationship Setting: IG 6 home visits with VIPP-SD; CG 6 phone calls with general information, no advice LOE; Decision for practice/ application to practice LOE: II Strengths: high LOE, randomization, & standardized measures. Weakness: small sample, and medium attrition. Feasibility: home visit setting is not feasible for the target population, but VIPP-SD is Key: ACE- adverse childhood experience; ANOVA- analysis of variance; APQ-S- Alabama Parenting Questionnaire-Short Form; AT- Attachment Theory; BDI-II- Beck Depression Inventory; BERS2- Behavioral and Emotional Rating Scale, 2nd Edition; CDSR- Cochrane Database of Systematic Reviews; CENTRAL- Cochrane Central Register of Controlled Trials; CG- control group; CHQ- Caregiving Helplessness Questionnaire; CT- Coercion Theory; Demosdemographics; DS- database search; DV- dependent variable; EC- exclusion criteria; ECBI- Eyberg Child Behavior Scale; F- female; FP7- Seventh Framework Programme; GAIN-SS- Global Appraisal of Individual Needs; HS- high school; IC- inclusion criteria; ICC-intraclass correlation coefficient; IS- intervention satisfaction; IV- independent variable; LOE- level of evidence; M- mean age; MA- meta-analysis; MCAR- Little’s missing at random test; MP- mom power; MSPSS- Multidimensional Scale of Perceived Social Support; n- number of participants (if SR) or number of participants in subset; N- number of studies (if SR) or participants in study; NHA- nurtured heart approach; NIH- National Institutes of Health registry of clinical trials; NRNCT- non-randomized non-controlled trial; NRCT- non-randomized controlled trial; NS- not stated; NSig- not significant; NWS-PTSD- National Women's Study PTSD Module; PARYC- Parenting Young Children Scale; PCCTS- Parent-Child Conflict Tactics Scale; PDSS- postpartum depression screening scale; PI- parenting intervention; PP- parenting program; PPI- parent practices interview; PRQ- Parenting Relationship Questionnaire; PSI- Parenting Stress Index; PSOC- Parenting Sense of Competence Scale; PTSD- post traumatic stress disorder; RCT- randomized control trial; SDQ- Strength and Difficulties Questionnaire; SLT- Social Learning Theory; SNsensitivity; SOCS- Sinovuyo Observational Coding System; SP- specificity; SR- systematic review; SS- search string; TE- trauma exposure; VIPP-SD- Videofeedback Intervention to promote Positive Parenting and Sensitive Discipline; WHO- World Health Organization registry of clinical trials; WMCI- Working Model of the Child Interview ACES AND MATERNAL EDUCATION 38 Table 1 Evaluation Table Citation Citation Theory/ Conceptual Framework Theory/ Conceptual Framework Design/ Method Sample/ Setting Design/ Method Inclusion: Portuguese children living with biological mother as primary caregiver. Exclusion: families receiving formal parenting training; Ethnic minorities and severe medical conditions. Attrition: 20% Sample/ Setting Major Variables & Definitions Measurement/ Instrumentatio n Data Analysis Findings/ Results LOE; Decision for practice/ application to practice worth looking into. Utility to PICOT: Address high risk population similar to project population, and intervention focused on parent-child communicatio n & discipline. Major Variables Measurement/ Instrumentatio n Data Analysis Findings/ Results LOE; Decision for practice/ Key: ACE- adverse childhood experience; ANOVA- analysis of variance; APQ-S- Alabama Parenting Questionnaire-Short Form; AT- Attachment Theory; BDI-II- Beck Depression Inventory; BERS2- Behavioral and Emotional Rating Scale, 2nd Edition; CDSR- Cochrane Database of Systematic Reviews; CENTRAL- Cochrane Central Register of Controlled Trials; CG- control group; CHQ- Caregiving Helplessness Questionnaire; CT- Coercion Theory; Demosdemographics; DS- database search; DV- dependent variable; EC- exclusion criteria; ECBI- Eyberg Child Behavior Scale; F- female; FP7- Seventh Framework Programme; GAIN-SS- Global Appraisal of Individual Needs; HS- high school; IC- inclusion criteria; ICC-intraclass correlation coefficient; IS- intervention satisfaction; IV- independent variable; LOE- level of evidence; M- mean age; MA- meta-analysis; MCAR- Little’s missing at random test; MP- mom power; MSPSS- Multidimensional Scale of Perceived Social Support; n- number of participants (if SR) or number of participants in subset; N- number of studies (if SR) or participants in study; NHA- nurtured heart approach; NIH- National Institutes of Health registry of clinical trials; NRNCT- non-randomized non-controlled trial; NRCT- non-randomized controlled trial; NS- not stated; NSig- not significant; NWS-PTSD- National Women's Study PTSD Module; PARYC- Parenting Young Children Scale; PCCTS- Parent-Child Conflict Tactics Scale; PDSS- postpartum depression screening scale; PI- parenting intervention; PP- parenting program; PPI- parent practices interview; PRQ- Parenting Relationship Questionnaire; PSI- Parenting Stress Index; PSOC- Parenting Sense of Competence Scale; PTSD- post traumatic stress disorder; RCT- randomized control trial; SDQ- Strength and Difficulties Questionnaire; SLT- Social Learning Theory; SNsensitivity; SOCS- Sinovuyo Observational Coding System; SP- specificity; SR- systematic review; SS- search string; TE- trauma exposure; VIPP-SD- Videofeedback Intervention to promote Positive Parenting and Sensitive Discipline; WHO- World Health Organization registry of clinical trials; WMCI- Working Model of the Child Interview ACES AND MATERNAL EDUCATION 39 Table 1 Evaluation Table Citation Ludmer et al., (2017). Accounting for the impact of parent internalizing symptoms on parent training benefits: The role of positive parenting. Funding: Ontario Mental Health Foundation, Canadian Child Health Clinician Scientist Program, Theory/ Conceptual Framework Theory of SelfEfficacy/Social Cognitive Theory inferred Design/ Method Design: Substudy of RCT pre & posttest Purpose: examine parent lifetime internalizing symptoms and high child emotional and behavioral difficulties post-PI. Sample/ Setting N= 114 Demos: 48% parents receiving group intervention, 50% child is medication for behavior disorder, 67% completed post secondary school, 40% married, 82% biological mother Setting: parents Major Variables & Definitions & Definitions IV1: internalizing symptoms Measurement/ Instrumentatio n Data Analysis Findings/ Results IV: GAIN-SS MCAR; ANOVA DV1: path c=0.19, SE=0.36, t= 0.51, ns. DV1: SDQ DV1: child behavior difficulties Mediators 1: parenting efficacy 2: positive parenting 3: inconsistent discipline 4: poor supervision Mediators 1: PSOC 2-4: APQ-S with 3 subscales: positive parenting, inconsistent discipline, & poor supervision Mediators 1: p= 0.06 2: p < 0.05 3-4: not significant LOE; Decision for practice/ application to practice application to practice LOE: III Strengths: medium LOE, analysis of variables and mediators, published in past 2 years. Weakness: medium-high attrition, use of parent reports, all internalizing symptoms not accounted for. Key: ACE- adverse childhood experience; ANOVA- analysis of variance; APQ-S- Alabama Parenting Questionnaire-Short Form; AT- Attachment Theory; BDI-II- Beck Depression Inventory; BERS2- Behavioral and Emotional Rating Scale, 2nd Edition; CDSR- Cochrane Database of Systematic Reviews; CENTRAL- Cochrane Central Register of Controlled Trials; CG- control group; CHQ- Caregiving Helplessness Questionnaire; CT- Coercion Theory; Demosdemographics; DS- database search; DV- dependent variable; EC- exclusion criteria; ECBI- Eyberg Child Behavior Scale; F- female; FP7- Seventh Framework Programme; GAIN-SS- Global Appraisal of Individual Needs; HS- high school; IC- inclusion criteria; ICC-intraclass correlation coefficient; IS- intervention satisfaction; IV- independent variable; LOE- level of evidence; M- mean age; MA- meta-analysis; MCAR- Little’s missing at random test; MP- mom power; MSPSS- Multidimensional Scale of Perceived Social Support; n- number of participants (if SR) or number of participants in subset; N- number of studies (if SR) or participants in study; NHA- nurtured heart approach; NIH- National Institutes of Health registry of clinical trials; NRNCT- non-randomized non-controlled trial; NRCT- non-randomized controlled trial; NS- not stated; NSig- not significant; NWS-PTSD- National Women's Study PTSD Module; PARYC- Parenting Young Children Scale; PCCTS- Parent-Child Conflict Tactics Scale; PDSS- postpartum depression screening scale; PI- parenting intervention; PP- parenting program; PPI- parent practices interview; PRQ- Parenting Relationship Questionnaire; PSI- Parenting Stress Index; PSOC- Parenting Sense of Competence Scale; PTSD- post traumatic stress disorder; RCT- randomized control trial; SDQ- Strength and Difficulties Questionnaire; SLT- Social Learning Theory; SNsensitivity; SOCS- Sinovuyo Observational Coding System; SP- specificity; SR- systematic review; SS- search string; TE- trauma exposure; VIPP-SD- Videofeedback Intervention to promote Positive Parenting and Sensitive Discipline; WHO- World Health Organization registry of clinical trials; WMCI- Working Model of the Child Interview ACES AND MATERNAL EDUCATION 40 Table 1 Evaluation Table Citation University of Toronto Bias: None identified Country: Canada Theory/ Conceptual Framework Design/ Method Sample/ Setting involved in RCT comparing group PI vs individual PI in outpatient clinic setting. Exclusion: NS – sub-study of RCT; RCT found no significant difference between group and individual PI Attrition: 24% (common for subject of study) Major Variables & Definitions Measurement/ Instrumentatio n Data Analysis Findings/ Results LOE; Decision for practice/ application to practice Feasibility: the main takeaway is the importance of incorporating positive parenting skills into PI. Utility to PICOT: Applicable to all aspects of the PICOT particularly PI. Key: ACE- adverse childhood experience; ANOVA- analysis of variance; APQ-S- Alabama Parenting Questionnaire-Short Form; AT- Attachment Theory; BDI-II- Beck Depression Inventory; BERS2- Behavioral and Emotional Rating Scale, 2nd Edition; CDSR- Cochrane Database of Systematic Reviews; CENTRAL- Cochrane Central Register of Controlled Trials; CG- control group; CHQ- Caregiving Helplessness Questionnaire; CT- Coercion Theory; Demosdemographics; DS- database search; DV- dependent variable; EC- exclusion criteria; ECBI- Eyberg Child Behavior Scale; F- female; FP7- Seventh Framework Programme; GAIN-SS- Global Appraisal of Individual Needs; HS- high school; IC- inclusion criteria; ICC-intraclass correlation coefficient; IS- intervention satisfaction; IV- independent variable; LOE- level of evidence; M- mean age; MA- meta-analysis; MCAR- Little’s missing at random test; MP- mom power; MSPSS- Multidimensional Scale of Perceived Social Support; n- number of participants (if SR) or number of participants in subset; N- number of studies (if SR) or participants in study; NHA- nurtured heart approach; NIH- National Institutes of Health registry of clinical trials; NRNCT- non-randomized non-controlled trial; NRCT- non-randomized controlled trial; NS- not stated; NSig- not significant; NWS-PTSD- National Women's Study PTSD Module; PARYC- Parenting Young Children Scale; PCCTS- Parent-Child Conflict Tactics Scale; PDSS- postpartum depression screening scale; PI- parenting intervention; PP- parenting program; PPI- parent practices interview; PRQ- Parenting Relationship Questionnaire; PSI- Parenting Stress Index; PSOC- Parenting Sense of Competence Scale; PTSD- post traumatic stress disorder; RCT- randomized control trial; SDQ- Strength and Difficulties Questionnaire; SLT- Social Learning Theory; SNsensitivity; SOCS- Sinovuyo Observational Coding System; SP- specificity; SR- systematic review; SS- search string; TE- trauma exposure; VIPP-SD- Videofeedback Intervention to promote Positive Parenting and Sensitive Discipline; WHO- World Health Organization registry of clinical trials; WMCI- Working Model of the Child Interview ACES AND MATERNAL EDUCATION 41 Table 1 Evaluation Table Citation Theory/ Conceptual Framework Design/ Method Sample/ Setting Major Variables & Definitions Measurement/ Instrumentatio n Data Analysis Findings/ Results Citation Theory/ Conceptual Framework Design/ Method Sample/ Setting Major Variables & Definitions Measurement/ Instrumentatio n Data Analysis Findings/ Results Juffer et al., (2017). Effective preventive interventions to support parents of young children: Illustrations from the videofeedback intervention to promote positive parenting and sensitive discipline (VIPPSD). AT; CT Design: MA N= 12 n= 1116 IV1: VIPPSD Cohen’s d Cohen’s d = 0.47 Demos: parents or caregivers DV1: sensitive parenting Child Behavior Checklist; observations; questionnaire Purpose: review of RCTs to examine VIPP-SD effectiveness. IC: use of VIPP-SD and measurement of sensitive parenting EC: NS LOE; Decision for practice/ application to practice LOE; Decision for practice/ application to practice LOE: I Strengths: high LOE, published in past two years. Weakness: Reviews a single program, & small number of studies. Feasibility: utilizing VIPP- Key: ACE- adverse childhood experience; ANOVA- analysis of variance; APQ-S- Alabama Parenting Questionnaire-Short Form; AT- Attachment Theory; BDI-II- Beck Depression Inventory; BERS2- Behavioral and Emotional Rating Scale, 2nd Edition; CDSR- Cochrane Database of Systematic Reviews; CENTRAL- Cochrane Central Register of Controlled Trials; CG- control group; CHQ- Caregiving Helplessness Questionnaire; CT- Coercion Theory; Demosdemographics; DS- database search; DV- dependent variable; EC- exclusion criteria; ECBI- Eyberg Child Behavior Scale; F- female; FP7- Seventh Framework Programme; GAIN-SS- Global Appraisal of Individual Needs; HS- high school; IC- inclusion criteria; ICC-intraclass correlation coefficient; IS- intervention satisfaction; IV- independent variable; LOE- level of evidence; M- mean age; MA- meta-analysis; MCAR- Little’s missing at random test; MP- mom power; MSPSS- Multidimensional Scale of Perceived Social Support; n- number of participants (if SR) or number of participants in subset; N- number of studies (if SR) or participants in study; NHA- nurtured heart approach; NIH- National Institutes of Health registry of clinical trials; NRNCT- non-randomized non-controlled trial; NRCT- non-randomized controlled trial; NS- not stated; NSig- not significant; NWS-PTSD- National Women's Study PTSD Module; PARYC- Parenting Young Children Scale; PCCTS- Parent-Child Conflict Tactics Scale; PDSS- postpartum depression screening scale; PI- parenting intervention; PP- parenting program; PPI- parent practices interview; PRQ- Parenting Relationship Questionnaire; PSI- Parenting Stress Index; PSOC- Parenting Sense of Competence Scale; PTSD- post traumatic stress disorder; RCT- randomized control trial; SDQ- Strength and Difficulties Questionnaire; SLT- Social Learning Theory; SNsensitivity; SOCS- Sinovuyo Observational Coding System; SP- specificity; SR- systematic review; SS- search string; TE- trauma exposure; VIPP-SD- Videofeedback Intervention to promote Positive Parenting and Sensitive Discipline; WHO- World Health Organization registry of clinical trials; WMCI- Working Model of the Child Interview ACES AND MATERNAL EDUCATION 42 Table 1 Evaluation Table Citation Theory/ Conceptual Framework Design/ Method Sample/ Setting Major Variables & Definitions Measurement/ Instrumentatio n Data Analysis Findings/ Results Funding: Weldkinderen; Netherlands Organization for Scientific Research Bias: None identified Country: Netherlands Citation Theory/ Conceptual Framework Design/ Method Sample/ Setting Major Variables & Definitions Measurement/ Instrumentatio n Data Analysis Findings/ Results LOE; Decision for practice/ application to practice SD is not realistic, but taking effective aspects from it will enhance project PI. Utility to PICOT: Particularly useful for intervention, but applicable to population too. LOE; Decision for practice/ application to practice Key: ACE- adverse childhood experience; ANOVA- analysis of variance; APQ-S- Alabama Parenting Questionnaire-Short Form; AT- Attachment Theory; BDI-II- Beck Depression Inventory; BERS2- Behavioral and Emotional Rating Scale, 2nd Edition; CDSR- Cochrane Database of Systematic Reviews; CENTRAL- Cochrane Central Register of Controlled Trials; CG- control group; CHQ- Caregiving Helplessness Questionnaire; CT- Coercion Theory; Demosdemographics; DS- database search; DV- dependent variable; EC- exclusion criteria; ECBI- Eyberg Child Behavior Scale; F- female; FP7- Seventh Framework Programme; GAIN-SS- Global Appraisal of Individual Needs; HS- high school; IC- inclusion criteria; ICC-intraclass correlation coefficient; IS- intervention satisfaction; IV- independent variable; LOE- level of evidence; M- mean age; MA- meta-analysis; MCAR- Little’s missing at random test; MP- mom power; MSPSS- Multidimensional Scale of Perceived Social Support; n- number of participants (if SR) or number of participants in subset; N- number of studies (if SR) or participants in study; NHA- nurtured heart approach; NIH- National Institutes of Health registry of clinical trials; NRNCT- non-randomized non-controlled trial; NRCT- non-randomized controlled trial; NS- not stated; NSig- not significant; NWS-PTSD- National Women's Study PTSD Module; PARYC- Parenting Young Children Scale; PCCTS- Parent-Child Conflict Tactics Scale; PDSS- postpartum depression screening scale; PI- parenting intervention; PP- parenting program; PPI- parent practices interview; PRQ- Parenting Relationship Questionnaire; PSI- Parenting Stress Index; PSOC- Parenting Sense of Competence Scale; PTSD- post traumatic stress disorder; RCT- randomized control trial; SDQ- Strength and Difficulties Questionnaire; SLT- Social Learning Theory; SNsensitivity; SOCS- Sinovuyo Observational Coding System; SP- specificity; SR- systematic review; SS- search string; TE- trauma exposure; VIPP-SD- Videofeedback Intervention to promote Positive Parenting and Sensitive Discipline; WHO- World Health Organization registry of clinical trials; WMCI- Working Model of the Child Interview ACES AND MATERNAL EDUCATION 43 Table 1 Evaluation Table Citation Theory/ Conceptual Framework Design/ Method Sample/ Setting Major Variables & Definitions Measurement/ Instrumentatio n Data Analysis Findings/ Results Durrant et al., (2014). Preventing punitive violence: Preliminary data on the positive discipline in everyday parenting (PDEP) program. Theory of Planned Behavior/Socia l Cognitive Theory Design: NRNCT (pre and posttest pilot study) N= 321 IV1: PDEP Questionnaires Demos: 87% F, 72% ages 2140 years, 80 % completed high school or beyond, 67% had 1-2 children. DV1: attitudes toward physical punishment DV2: subjective norms regarding parent-child conflict DV3: selfefficacy Wilcoxon signed-rank tests; Cohen’s d DV1: p < 0.001 DV2: p < 0.001 DV3: p < 0.001 Funding: NS Bias: None identified Purpose: provide a preliminary assessment of the impact of PDEP on parents. Setting: community group setting of eight 90-minute sessions. Country: Canada Exclusion: NS Attrition: 23% LOE; Decision for practice/ application to practice LOE: IV Strengths: statistically significant results, thorough program design. Weakness: lacked CG, no measurement of individual change. Feasibility: setting is feasible, would likely need to Key: ACE- adverse childhood experience; ANOVA- analysis of variance; APQ-S- Alabama Parenting Questionnaire-Short Form; AT- Attachment Theory; BDI-II- Beck Depression Inventory; BERS2- Behavioral and Emotional Rating Scale, 2nd Edition; CDSR- Cochrane Database of Systematic Reviews; CENTRAL- Cochrane Central Register of Controlled Trials; CG- control group; CHQ- Caregiving Helplessness Questionnaire; CT- Coercion Theory; Demosdemographics; DS- database search; DV- dependent variable; EC- exclusion criteria; ECBI- Eyberg Child Behavior Scale; F- female; FP7- Seventh Framework Programme; GAIN-SS- Global Appraisal of Individual Needs; HS- high school; IC- inclusion criteria; ICC-intraclass correlation coefficient; IS- intervention satisfaction; IV- independent variable; LOE- level of evidence; M- mean age; MA- meta-analysis; MCAR- Little’s missing at random test; MP- mom power; MSPSS- Multidimensional Scale of Perceived Social Support; n- number of participants (if SR) or number of participants in subset; N- number of studies (if SR) or participants in study; NHA- nurtured heart approach; NIH- National Institutes of Health registry of clinical trials; NRNCT- non-randomized non-controlled trial; NRCT- non-randomized controlled trial; NS- not stated; NSig- not significant; NWS-PTSD- National Women's Study PTSD Module; PARYC- Parenting Young Children Scale; PCCTS- Parent-Child Conflict Tactics Scale; PDSS- postpartum depression screening scale; PI- parenting intervention; PP- parenting program; PPI- parent practices interview; PRQ- Parenting Relationship Questionnaire; PSI- Parenting Stress Index; PSOC- Parenting Sense of Competence Scale; PTSD- post traumatic stress disorder; RCT- randomized control trial; SDQ- Strength and Difficulties Questionnaire; SLT- Social Learning Theory; SNsensitivity; SOCS- Sinovuyo Observational Coding System; SP- specificity; SR- systematic review; SS- search string; TE- trauma exposure; VIPP-SD- Videofeedback Intervention to promote Positive Parenting and Sensitive Discipline; WHO- World Health Organization registry of clinical trials; WMCI- Working Model of the Child Interview ACES AND MATERNAL EDUCATION 44 Table 1 Evaluation Table Citation Theory/ Conceptual Framework Design/ Method Sample/ Setting Major Variables & Definitions Measurement/ Instrumentatio n Data Analysis Findings/ Results LOE; Decision for practice/ application to practice decrease session time. Utility to PICOT: applicable to intervention and population. Leijten et al., (2017). Effectiveness of the incredible years parenting program for families with socioeconomicall y disadvantaged and ethnic SLT Design: RCT N= 154 IV1: PI Purpose: examined whether the Incredible Years parenting program is differentially Demos: child M= 6 years, child gender 40% F, maternal M= 34. DV1: child disruptive behavior DV2: child problem behavior ECBI, SDQ, PPI, PSI ANOVA; paired samples t test DV1: p<0.001 DV2: p< 0.05 DV3: NSig DV4: p<0.001 DV5: NSig LOE: II Strengths: hard to reach population, high LOE, published past two years. Key: ACE- adverse childhood experience; ANOVA- analysis of variance; APQ-S- Alabama Parenting Questionnaire-Short Form; AT- Attachment Theory; BDI-II- Beck Depression Inventory; BERS2- Behavioral and Emotional Rating Scale, 2nd Edition; CDSR- Cochrane Database of Systematic Reviews; CENTRAL- Cochrane Central Register of Controlled Trials; CG- control group; CHQ- Caregiving Helplessness Questionnaire; CT- Coercion Theory; Demosdemographics; DS- database search; DV- dependent variable; EC- exclusion criteria; ECBI- Eyberg Child Behavior Scale; F- female; FP7- Seventh Framework Programme; GAIN-SS- Global Appraisal of Individual Needs; HS- high school; IC- inclusion criteria; ICC-intraclass correlation coefficient; IS- intervention satisfaction; IV- independent variable; LOE- level of evidence; M- mean age; MA- meta-analysis; MCAR- Little’s missing at random test; MP- mom power; MSPSS- Multidimensional Scale of Perceived Social Support; n- number of participants (if SR) or number of participants in subset; N- number of studies (if SR) or participants in study; NHA- nurtured heart approach; NIH- National Institutes of Health registry of clinical trials; NRNCT- non-randomized non-controlled trial; NRCT- non-randomized controlled trial; NS- not stated; NSig- not significant; NWS-PTSD- National Women's Study PTSD Module; PARYC- Parenting Young Children Scale; PCCTS- Parent-Child Conflict Tactics Scale; PDSS- postpartum depression screening scale; PI- parenting intervention; PP- parenting program; PPI- parent practices interview; PRQ- Parenting Relationship Questionnaire; PSI- Parenting Stress Index; PSOC- Parenting Sense of Competence Scale; PTSD- post traumatic stress disorder; RCT- randomized control trial; SDQ- Strength and Difficulties Questionnaire; SLT- Social Learning Theory; SNsensitivity; SOCS- Sinovuyo Observational Coding System; SP- specificity; SR- systematic review; SS- search string; TE- trauma exposure; VIPP-SD- Videofeedback Intervention to promote Positive Parenting and Sensitive Discipline; WHO- World Health Organization registry of clinical trials; WMCI- Working Model of the Child Interview ACES AND MATERNAL EDUCATION 45 Table 1 Evaluation Table Citation minority backgrounds. Funding: Netherlands Organisation for Health Research and Development Bias: None identified Country: Netherlands Theory/ Conceptual Framework Design/ Method Sample/ Setting Major Variables & Definitions effective for families with different socioeconomi c status and ethnic backgrounds. Setting: community setting; 12-18 two hour sessions. DV3: parent rating of regression DV4: parenting practices DV5: parent stress Exclusion: NS Attrition: 27% Measurement/ Instrumentatio n Data Analysis Findings/ Results LOE; Decision for practice/ application to practice Weakness: parent reported, missing data, medium high attrition. Feasibility: program is too long, but core concepts can by utilized. Utility to PICOT: applicable to intervention and population. Key: ACE- adverse childhood experience; ANOVA- analysis of variance; APQ-S- Alabama Parenting Questionnaire-Short Form; AT- Attachment Theory; BDI-II- Beck Depression Inventory; BERS2- Behavioral and Emotional Rating Scale, 2nd Edition; CDSR- Cochrane Database of Systematic Reviews; CENTRAL- Cochrane Central Register of Controlled Trials; CG- control group; CHQ- Caregiving Helplessness Questionnaire; CT- Coercion Theory; Demosdemographics; DS- database search; DV- dependent variable; EC- exclusion criteria; ECBI- Eyberg Child Behavior Scale; F- female; FP7- Seventh Framework Programme; GAIN-SS- Global Appraisal of Individual Needs; HS- high school; IC- inclusion criteria; ICC-intraclass correlation coefficient; IS- intervention satisfaction; IV- independent variable; LOE- level of evidence; M- mean age; MA- meta-analysis; MCAR- Little’s missing at random test; MP- mom power; MSPSS- Multidimensional Scale of Perceived Social Support; n- number of participants (if SR) or number of participants in subset; N- number of studies (if SR) or participants in study; NHA- nurtured heart approach; NIH- National Institutes of Health registry of clinical trials; NRNCT- non-randomized non-controlled trial; NRCT- non-randomized controlled trial; NS- not stated; NSig- not significant; NWS-PTSD- National Women's Study PTSD Module; PARYC- Parenting Young Children Scale; PCCTS- Parent-Child Conflict Tactics Scale; PDSS- postpartum depression screening scale; PI- parenting intervention; PP- parenting program; PPI- parent practices interview; PRQ- Parenting Relationship Questionnaire; PSI- Parenting Stress Index; PSOC- Parenting Sense of Competence Scale; PTSD- post traumatic stress disorder; RCT- randomized control trial; SDQ- Strength and Difficulties Questionnaire; SLT- Social Learning Theory; SNsensitivity; SOCS- Sinovuyo Observational Coding System; SP- specificity; SR- systematic review; SS- search string; TE- trauma exposure; VIPP-SD- Videofeedback Intervention to promote Positive Parenting and Sensitive Discipline; WHO- World Health Organization registry of clinical trials; WMCI- Working Model of the Child Interview ACES AND MATERNAL EDUCATION 46 Appendix B Table 2 Interventions 2018 I 2018 I NRNCT 100% 24 yrs X 99 PDSS; NWSPTSD; CHQ AT; SLT X SR MA 40 (S) Biomarkers 21(S) PSI; CBC X FST X X X X Group Setting X X X X X One-on-One Instructor led Education X X X X X X X X Design Female Mean Age Parent Community Setting # Of participants/studies(S) Measurement Tools Theories Utilized Positive Parenting Education Parent Only Video Education X 2017 II 2016 IV RCT NRCT 100% 74% 34 yrs X X 68 416 PCCTS; PRQ; PDS; ECBI; BERS2 PSI; MSPSS AT; SLT DT X X X Leijan et al. Durrant et al. Juffer et al. Ludmer et al. Pereira et al. Brennan et al. Lachman et al. Lindstrom et al. 2015 IV Tools Basics Year LOE Purewal et al. Studies Muzik et al. Synthesis Table 2014 II 2017 III 2017 I 2014 IV 2017 II RCT 100% 30 yrs X 44 DHQ RCT-SS MA X 114 GAIN-SS SDQ 12(S) CBC NRNCT 87% 31 yrs X 321 Questionnaire RCT 100% 34 yrs X 154 ECBI; SDQ; PPI; PSI AT; CT X SLT X AT; CT X TPB; SLT X SLT X X X X X X X X X X X X Key: Key: AT- Attachment Theory; BERS2- Behavioral and Emotional Rating Scale, 2nd edition; CBC- Child Behavior Checklist; CHQ- Caregiving Helplessness Questionnaire; CT- Coercion Theory; DHQ- Daily Hassles Questionnaire; DT- Developmental Theory; ECBI- Eyberg Child Behavior Scale; FSTFamily Systems Theory; GAIN-SS- Global Appraisal of Individual Needs; MA- meta-analysis; MH- mental health; MSPSS- Multidimensional Scale of Perceived Social Support; NRCT- non-randomized controlled trial; NRNCT- non-randomized non-controlled trial; ns- not significant; NWS-PTSD- National Women's Study Post Traumatic Stress Disorder Module; PCCTS- Parent-Child Conflict Tactics Scale; PDS- Parent Discipline Scales; PDSS- postpartum depression screening scale; PPI- parent practice interview; PRQ- Parenting Relationship Questionnaire; PSI- Parenting Stress Index; RCT- Randomized Control Trial; SS- randomized control trial sub-study; SDQ- Strength and Difficulties Questionnaire; SLT- Social Learning Theories; SR- systematic review; TPBTheory of Planned Behavior; X- significant; ↑- increased; ↓- decreased ACES AND MATERNAL EDUCATION 47 Table 2 Major findings Synthesis Table Improved Parent MH X Positive Parenting Competence Parenting Stress ↑ Parent Self-Efficacy ↑ ns X ↑ ↑ ↑ ↓ ns ↑ ↓ ns ↓ Improved Child Behavior X X X X ↑ ↑ ↑ ↓ Harsh Discipline Improved Child Health ↑ ↑ ns ↑ ↓ ↓ X X Key: Key: AT- Attachment Theory; BERS2- Behavioral and Emotional Rating Scale, 2nd edition; CBC- Child Behavior Checklist; CHQ- Caregiving Helplessness Questionnaire; CT- Coercion Theory; DHQ- Daily Hassles Questionnaire; DT- Developmental Theory; ECBI- Eyberg Child Behavior Scale; FSTFamily Systems Theory; GAIN-SS- Global Appraisal of Individual Needs; MA- meta-analysis; MH- mental health; MSPSS- Multidimensional Scale of Perceived Social Support; NRCT- non-randomized controlled trial; NRNCT- non-randomized non-controlled trial; ns- not significant; NWS-PTSD- National Women's Study Post Traumatic Stress Disorder Module; PCCTS- Parent-Child Conflict Tactics Scale; PDS- Parent Discipline Scales; PDSS- postpartum depression screening scale; PPI- parent practice interview; PRQ- Parenting Relationship Questionnaire; PSI- Parenting Stress Index; RCT- Randomized Control Trial; SS- randomized control trial sub-study; SDQ- Strength and Difficulties Questionnaire; SLT- Social Learning Theories; SR- systematic review; TPBTheory of Planned Behavior; X- significant; ↑- increased; ↓- decreased ACES AND MATERNAL EDUCATION 48 Appendix C Figure 1 The Stetler Model ACES AND MATERNAL EDUCATION 49 ACES AND MATERNAL EDUCATION 50 Appendix D Table 3 Budget Plan Phase Preparation Activities Creation of workshops (48 hrs @ $0/hr) Binders for workshop (30) Print documents for binder (30 per binder) Dividers for binders (30 packs) Pens for participants Print pre & post evaluation tool (60) Delivery Evaluation Cost Subtotal Total $0 $2.50 $75 $3.00 ($0.10/sheet) $1.10 $90 $33 $5 $0.10 Classroom for workshop* $0 Projector* $0 Utilities* (electric, air conditioning, internet) Child counselor present for workshops* (6 hrs @ $0/hr) Tabletop Easel Pad $0 $20 Raffle prize after participation $25 Review and analysis of results with SPSS software $75 $6 $0 $329